Osteopaths on the loose... [Archive]

Blue Wode

30th April 2008, 11:54 AM

Here is the website of The British Institute of Osteopathy - a ‘recognising’ body as opposed to a registering body.
http://www.british-institute-of-osteopathy.org/Default.aspx

Cue alarm bells…

There are no 'diseases' or 'cures' only obstructions to natural processes More (http://www.british-institute-of-osteopathy.org/traditional/Default.aspx#4#4)

Why randomised controlled trials (RCTs) don't work More (http://www.british-institute-of-osteopathy.org/traditional/Default.aspx#8#8)

Vaccination, innoculation immunisation: the osteopathic perspective More (http://www.british-institute-of-osteopathy.org/traditional/Default.aspx#14#14)

http://www.british-institute-of-osteopathy.org/traditional/Default.aspx#14

SPRING 2008 EVENTS

'So you think diseases are caused by little germy-wermies?'

After the great success of our autumn first conference, exploring the first osteopathic principles of natural immunity and structural integrity, an evening seminar exposing the modern medical mythology of germ theory is required.

It is impossible to learn to both appreciate and practice traditional osteopathic methods if the colleges continue to teach the non-evidence based germ causative disease theories. These are routinely taught as factual base for pathology.

One very good example of this is the 1917 flu pandemic. The mortality rate at osteopathic hospitals in America using articulation to keep fluids moving and non-suppressive fever management to allow the cleaning crisis was ¼%!

By contrast the mortality rate at allopathic hospitals that used palliative methods of morphine based cough suppressants and aspirin to suppress the fever was in some cases 70%! Evidence enough of the disaster that palliation can lead to.

Dr Patrick Quanten MD, who has already written two articles for the website, will eloquently take apart this modern medical myth. With many examples to explain a far more evidence based understanding of the role that microorganisms play in health.

Howard Beardmore DO will follow this, with evidence from Still and Littlejohn and other osteopaths, showing that they did not focus on killing germs to both understand and treat so called 'infection'. Coupled with case history evidence, of the management of the cleaning crisis, the evening will attempt to dispel the fearful lack of knowledge that medical pathology seems to have instilled in our profession.

http://www.british-institute-of-osteopathy.org/Events/Default.aspx

It’s really quite worrying that these osteopaths seem to be able to get away with the above despite their profession being statutorily regulated. (Presumably the osteopaths who belong to this organisation are regulated by the General Osteopathic Council, but manage to evade accountability because their scope of practice isn’t defined or limited.)

Perhaps of even greater concern is that some chiropractors seem set to go a step further. A few weeks ago, I read on a chiropractic forum (which is now, unfortunately, accessible to invited members only) that several dozen chiropractors were thinking of rebelling against their regulatory status. Apparently they are going to cancel their registration with the General Chiropractic Council in the full knowledge that - to all intents and purposes - they will still be able to do what chiropractors do providing they don’t call themselves ‘chiropractors’.

So what all of this seems to boil down to is what is the point of regulation when it seems to be toothless in calling a halt to the assorted (dangerous) quackery espoused by not only its registered practitioners, but also by those who de-register and continue to practice under another title?

Interesting further reading…
http://thinking-is-dangerous.blogspot.com/2008/04/get-ideal-spine-have-quack-crack-your.html

…especially this bit from Le Canard Noir in the Comments section:

'osteomyologist' - another made up word that covers all those who will not or cannot call themselves chiropractors or osteopaths. Calling yourself an 'osteomyologist' neatly sidesteps statutory regulation

filippo lippi

30th April 2008, 01:02 PM

Shocking.

The parents are heavily into this woo. Unfortanately their osteopath of choice diagnosed a serious condition in my father's leg where the GP had repeatedly failed. Obviously, the osteopath could do nothing about the condition and it was left up to proper doctors and surgeons to sort out, but because the quack made the correct diagnosis he can do know wrong in the parents' eyes.

Skeptiger

30th April 2008, 05:26 PM

Ok, I am going to show my ignorance here...I knew that chiropractors were firmly in the woo camp, but (and don't shoot me down here, please!) I hadn't realised osteopaths were in that camp as well? I possibly didn't do enough research when I was in rather excruciating pain with sciatica, but my GP recommended I see an osteopath for my back? I deliberately avoided a chiropractor, but went to an osteopath thinking that they were medically trained...

Can someone give me a bit of background? Was it a poor decision? The problem, as I know we all agree, is it is really tough to tell the difference nowadays between real medicine and CAM, as the latter is so mainstream.

Neuromuscular Therapist

30th April 2008, 06:31 PM

Fillippo,

The fact that the osteopath diagnosed the problem with your father's leg where his GP couldn't, must count for something. He obviously did know what he was doing.

In the USA osteopaths are medically trained. There are two types of docs, MD'S and DO's. They are the same and go through med school learning the same things, except that DO's have the addition of other lectures that are directly related to osteopathy. They can prescribe and undertake the same training programs as MD's and you can get DO surgeons.

However, in Europe, UK and Canada osteopaths are not doctors, but do have quite extensive training. Most osteopathic courses are at least four years long, with some being five.

A lot of osteopaths are okay and are not quacks in the same way that chiros are. They actually do soft tissue work, which is more often that no needed during the course of treatment, whereas most chiros do not.

filippo lippi

30th April 2008, 07:09 PM

The fact that the osteopath diagnosed the problem with your father's leg where his GP couldn't, must count for something. He obviously did know what he was doing.

So he's shooting 1 for what? They both have chronic injuries that the osteopath has been "treating" for years. And he's not American.

And then there's this

CONCLUSION

The traditional osteopathic perspective does not support the allopathic view that micro organisms are causative in disease but they are part of a vigorous, adaptive cleaning process that ultimately leads to a restoration of health.
Treatments designed to modify micro organisms, or kill them directly; infer no benefit to the body and may indeed start a pathway to degeneration by denying the body the opportunity to clean and repair itself. Evidence of the transmutation of ordinary body cells into specific micro organisms and viruses in the presence of waste laden tissue is a normal extension of the body's natural immunity. It is a self limiting process dependant on the completion of the task to remove waste that sees the transmutation back to ordinary body cells at it's conclusion.

from here

http://www.british-institute-of-osteopathy.org/articles/the_role_of_micro_organisms.aspx

Is this indicative of what Osteopaths are taught? 'Cos four years of learning this (unless I've comletely misread the above) shit don't impress me.

filippo lippi

30th April 2008, 07:15 PM

There's more

Now then!

Germs are made by your body in an effort to clear up a messy environment. Once this has been achieved they will automatically disappear again. Proven several times in the last 150 years alone, and still not accepted in our world.
Don't be cynical: it has nothing whatsoever to do with vaccines and germ killing substances, and the financial lucrative businesses of making and selling them; not to mention the high regard in which all these cleaver brains are held and the jobs they are holding on to.

These people want locking up before they hurt someone

Mongrel

30th April 2008, 10:57 PM

S
CONCLUSION

The traditional osteopathic perspective does not support the allopathic view

Highlighted word is also a big warning sign. Allopathy, as a word, was invented by Hahnemann to distance homeopathy from the normal medical practices of the day. Now it is generally used as a pejorative by Alt med proponents.

filippo lippi

1st May 2008, 05:33 AM

According to the General Osteopathic Council glue ear, colic and sinus problems can be "treated effectively" and they can help "children suffering from cerebral palsy and Down's Syndrome."

Yeah, sure you can.

http://www.osteopathy.org.uk/about_osteo/Babies_Children.pdf

filippo lippi

1st May 2008, 05:37 AM

Hold on. Back up a minute there.

Dental problems? They can treat dental problems?

Seems to be indistinguishable from the claims of woo.

filippo lippi

1st May 2008, 05:39 AM

Perhaps the biggest red flag of them all...

http://www.osteopathy.org.uk/news/newsdetails.php?id=47

Neuromuscular Therapist

1st May 2008, 08:52 AM

Osteopaths are fundamentally not the same as Chiros.

Perhaps you should check this out properly before being so disparaging in your remarks?!

A lot of the techniques that I use as a Physical Therapist for lengthening shortened myofascia come from osteopathy. I use these because they work very well in cases where muscles need lengthening. I never use thrusting techniques, but rather exercises to strengthen and increase range of motion.

Mojo

1st May 2008, 09:18 AM

Blue Wode

1st May 2008, 09:47 AM

I wanted an actual link before I believed that one. Regrettably, I found it. http://www.british-institute-of-osteopathy.org/articles/origin_germs.aspx

It gets worse. The author of that article, Patrick Quanten, also appears to be heavily into ear candling:

Patrick Quanten concentrated on explaining in simple terms some relevant facts of quantum physics and new biology. All matter is energy condensed and all cells "listen" to everything that is going on in their environment. The combination of these allow the energetic influence of ear candling to be felt throughout the whole body, both via a direct influence on the cells and via the overall information distributed through the nervous network. He also showed that in free burning open candles only white smoke appeared at the bottom of the candle. The matter found inside the candles after burning only occurs by compressing the smoke. He suggested a relationship between what was found inside the burned candle and the changes made in the auric field of the person being candled.

http://freespace.virgin.net/ahcare.qua/index5.html (http://freespace.virgin.net/ahcare.qua/index5.html)

:shocked:

Skeptiger

1st May 2008, 11:06 AM

I am so confused now. :undecided:

The osteopath I went to see appeared to do nothing but backs and sports injuries. I chose him because I was running a marathon two weeks later and really needed help. As osteopath for a London Premiership Football team (not that that means much in relation to his legitimacy, but still), I kind of thought that sports issues would be important for him.

There was nothing at all around his office or reception that suggested any of the stuff that's been discussed.

And, he was even disparaging of chiropractors for being too woo woo!

Is it possible that there are some osteopaths which don't subscribe to the rubbish you've pointed out? Or am I being really naive (wouldn't be the first time!)

filippo lippi

1st May 2008, 12:13 PM

I wanted an actual link before I believed that one. Regrettably, I found it. http://www.british-institute-of-osteopathy.org/articles/origin_germs.aspx

Sorry, the red mist descends and then I wake up several hours later;)

filippo lippi

1st May 2008, 12:28 PM

Osteopaths are fundamentally not the same as Chiros.

Perhaps you should check this out properly before being so disparaging in your remarks?!

Perhaps you should read the links. I don't know about the British Institute Osteopaths, but the General Osteopathic Council appears to speak for the mainstream of osteopathy and it's endorsed by the Prince of Woo-les. Unless you have some evidence otherwise I'm going to assume that what they peddle is "mainstream."

How do you suppose an osteopath would treat an ear infection? Or learning difficulties? Or Sinus problems? How does an osteopath help someone with cerebral palsy or Down's Syndrome?

Lest we forget, these claims are made here

http://www.osteopathy.org.uk/about_osteo/Babies_Children.pdf

At the moment I'm having difficulty differentiating between these claims and those made by Gary Mannion.

Neuromuscular Therapist

1st May 2008, 12:43 PM

Is it possible that there are some osteopaths which don't subscribe to the rubbish you've pointed out? Or am I being really naive (wouldn't be the first time!)

No, you are not being naive at all. As I said in the States DO's are MD's have the same status, however, in the UK they undergo quite intense training over a four year period.

Lots of osteopaths specialise in sports osteopathy and the great thing is that they do soft tissue work which is always needed in cases such as yours. As a Physical Therapist, I predominantly work with soft tissue and I use a lot of osteopathic soft tissue techniques in my practice.

Neuromuscular Therapist

1st May 2008, 12:52 PM

How do you suppose an osteopath would treat an ear infection? Or learning difficulties? Or Sinus problems? How does an osteopath help someone with cerebral palsy or Down's Syndrome?

Ear and sinus problems can be helped by working on the musculature of the neck, sub-occipital muscles and the muscles that attach around the TMJ. Also the SCM which attaches at the mastoid tip. If muscles are tight in these areas proper drainage can be prevented. Once these muscles are lengthened, these problems can be overcome. However, there are other reasons apart from this that can cause ear and sinus problems which need to be considered.

filippo lippi

1st May 2008, 01:20 PM

And cerebral palsy? Down's syndrome? Learning difficulties?

Blue Wode

1st May 2008, 01:30 PM

Ear and sinus problems can be helped by working on the musculature of the neck, sub-occipital muscles and the muscles that attach around the TMJ. Also the SCM which attaches at the mastoid tip. If muscles are tight in these areas proper drainage can be prevented. Once these muscles are lengthened, these problems can be overcome. However, there are other reasons apart from this that can cause ear and sinus problems which need to be considered.
Do you have any good evidence to support that claim? Because let’s not forget what Professor Edzard Ernst and Simon Singh had to say very recently on the subject of osteopathy's effectiveness:

OSTEOPATHY

WHAT IS IT?
A manual therapy which focuses on the musculoskeletal system to treat disease. Osteopaths use a range of techniques to mobilise soft tissues, bones and joints. Osteopathy and chiropractic therapy have much in common, but there are also important differences.

Osteopaths tend to use gentler techniques and often employ massage-like treatments. They also place less emphasis on the spine than chiropractors, and they rarely move the vertebral joints beyond their physical range of motion, unlike chiropractors. Therefore osteopathic interventions are less likely to injure.

In general they treat mainly musculoskeletal problems, but many also claim to treat other conditions such as asthma, ear infection and colic.

DOES IT WORK?
There is reasonably good evidence that the osteopathic approach is as effective as conventional treatments for back pain (if, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercises, which is backed by similar evidence and which is more cost- effective as it is often done in groups).

There is no good evidence to support the use of osteopathy in non-musculoskeletal conditions.

People with severe osteoporosis, bone cancer, infections of the bone or bleeding problems should confirm with the osteopath that they will not receive forceful manual treatments.

http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=1774&ICO=HEALTH&ICL=TOPART (http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=1774&ICO=HEALTH&ICL=TOPART)

[My bold]

For those interested, this topic is also being discussed over at Bad Science at the moment:
http://badscience.net/forum/viewtopic.php?p=86674#86674 (http://badscience.net/forum/viewtopic.php?p=86674#86674)

For clarification purposes, the following is lifted from a post I made there earlier today about the main differences between osteopathy and chiropractic:

For those not familiar with both practices [chiropractic and osteopathy], the following is a summary of pages 130-135 of the ‘Bad Backs’ chapter of Rose Shapiro’s recently published book, Suckers: How alternative medicine makes fools of us all:

Chiropractors are more likely to manipulate the spine directly; osteopaths may use the limbs as levers and in this way try to mobilise the spine.

Both osteopathy and chiropractic originated in America. They were a development of the medieval folk medicine practice of bone setting.

In America today there are more than 49,000 Doctors of Osteopathy (known as DOs) who are trained in orthodox scientific medicine with additional training in manipulative therapies. They have the same entitlements to prescribe and perform surgery as mainstream medical practitioners and make up 20% of all general practitioners is the US.

The UK’s 5,000 or so osteopaths, require no scientific medical training and so are more firmly established in the ‘alternative’ camp. Very few are MDs and many combine osteopathy with dubious practices such as naturopathy and cranial osteopathy. They are regulated by statute.

In a review of current research that ‘enraged’ osteopaths and chiropractors, Professor Edzard Ernst concluded that here was no evidence to suggest that spinal manipulation was an effective intervention for any condition and that the finding applied to both osteopathy and chiropractic.

Osteopathy and chiropractic were invented, or ‘discovered’ by a pair of determined and charismatic Americans in the late 19th century – Andrew Taylor Still and Daniel David Palmer. They both could be described as chancers and fantasists who had tried and failed to make their fortunes in a variety of jobs and get-rich-quick schemes. They saw themselves as visionaries and spiritual leaders and believed they had discovered a single cause and a single cure for all diseases.

Andrew Still claimed he had been a battlefield surgeon, but no record of it exists. He found phrenology and mesmerism interesting and following the deaths of three of his children he became a magnetic healer. He went on to have a ”prophetic vision” which apparently revealed a truth to him that if bones could be manipulated back into alignment then the nerves would “properly conduct the fluids of life” and so-called diseases or effects would trouble the patient no longer. In the mid 1880s he coined the word ‘osteopathy’ and business was booming.
I don’t think that present-day osteopathy is quite so mired in quackery as chiropractic, however they are quite similar in that both use spinal manipulation – although it’s probably true to say that osteopaths tend to use it less in favour of soft tissue work (which is gentler).

Neuromuscular Therapist

1st May 2008, 02:09 PM

And cerebral palsy? Down's syndrome? Learning difficulties?

I don't know about that one. My guess would be probably not!

Neuromuscular Therapist

1st May 2008, 02:13 PM

Do you have any good evidence to support that claim? Because let’s not forget what Professor Edzard Ernst and Simon Singh had to say very recently on the subject of osteopathy's effectiveness:

Yes, because these techniques are not really osteopathy in general. What I have described are ways of working with and lengthening the soft tissues that do not involve manipulation of any kind that are used by osteopaths yes, but also massage therapists and physical therapists alike.

I believe it was the HVT/LVT that Ernst and Singh were saying had no good evidence and this is not what I am talking about.

filippo lippi

1st May 2008, 05:54 PM

Mongrel

1st May 2008, 09:00 PM

I believe it was the HVT/LVT that Ernst and Singh were saying had no good evidence and this is not what I am talking about.

But when they combine some useful techniques with bad and then throw in some made up stuff that refutes germ theory why not just go to a state registered Physio?

Cherry picking some proven treatments they use whilst ignoring that whole festering pile of wackiness is a bit short sighted...

Neuromuscular Therapist

2nd May 2008, 09:02 AM

But when they combine some useful techniques with bad and then throw in some made up stuff that refutes germ theory why not just go to a state registered Physio?

Cherry picking some proven treatments they use whilst ignoring that whole festering pile of wackiness is a bit short sighted...

This is because most osteopaths are actually not like this. I have had problems from time to time and have been to see some of my osteopathic colleagues for treatment and they have done some great soft tissue work using a lot of the techniques that I use in my own practice with great success.

Neuromuscular Therapist

2nd May 2008, 09:07 AM

I've been reading up about glue ear and sinusitis. Apparently, both conditions usually clear up by themselves and standard medical practice is to wait and see. Just the sort of problem the alt-medders love, "it'll probably clear up on its own and in the meantime, KER-CHING!"

The answer to this is that sometimes is does clear by itself, but not always and at times, other interventions are needed. Anyway, regardless of this, if someone came to see me with tight musculature in the areas I have already described, I would work on these areas, to break down adhesions and lengthen the tissue, to create freedom from pain and increased range of motion.

Remember though that I am a Licenced Physical Therapist and not an osteopath.

filippo lippi

2nd May 2008, 09:42 AM

The answer to this is that sometimes is does clear by itself, but not always and at times, other interventions are needed. Anyway, regardless of this, if someone came to see me with tight musculature in the areas I have already described, I would work on these areas, to break down adhesions and lengthen the tissue, to create freedom from pain and increased range of motion.

Remember though that I am a Licenced Physical Therapist and not an osteopath.

How do you decide whether other interventions are necessary? Is their any evidence that your interventions are more effective than "just wait and it'll probably clear up on it's own?" I am sceptical of your claims, but, as a life-long perrenial rhinitis sufferer I am quite interested in the possibility that there may be a non-pharmaceutical way of bringing relief, especially now the oil-seed rape is flowering.

Cuddles

2nd May 2008, 10:53 AM

I've been reading up about glue ear and sinusitis. Apparently, both conditions usually clear up by themselves and standard medical practice is to wait and see. Just the sort of problem the alt-medders love, "it'll probably clear up on its own and in the meantime, KER-CHING!"

For glue ear and other ear infections it depends on the position of the infection. If it's only an outer ear infection, then the standard approach would be simply to wait until it goes, although likely combined with ear drops or something else to help clear the wax. For middle ear infections, antibiotics are likely to be needed, usually after waiting a couple of days to make sure it's not just a short lived thing. Inner ear infections can sometimes require more drastic measures due to the risk of permanent hearing damage.

At no point will any real doctor recommend a massage for anything related to your ears.

filippo lippi

2nd May 2008, 11:25 AM

I thought not, but NT might come up with something; I'm sceptical, but open to the possibility.

With the old PR I used to suffer a lot of sinus infections, at least one a year. The GP never once recommended massage, the anti-hystamines seem to do the trick quite nicely.

Mongrel

2nd May 2008, 04:27 PM

This is because most osteopaths are actually not like this.

That's as maybe but if that's the case why aren't they willing to clean house to get rid of the 'minority' of quacks?

SKIRRID5

3rd May 2008, 04:35 PM

All this stuff about germs not being responsible for disease is, I believe, more or less what George Bernard Shaw believed. He was a celebrity, so it must be true!
I got this from a book well worth reading, if it's still around: The New Apocrypha, by the excellent SF writer, the late lamented John Sladek.

filippo lippi

16th May 2008, 07:57 AM

Neuromuscular Therapist

16th May 2008, 09:46 AM

Okay, you guys don't quite seem to have understood what I am saying.

This is to clarify the situation.

As a physical therapist and sports massage therapist, I work with musculo-skeletal problems. What I have found in my practice is that in some patients that I see who have musculo-skeletal problems also accompanied with either sinus problems or ear problems have found relief from these problems when I have worked on tight and shortened musculature in the areas of the neck and all the muscles in this area - upper traps, SCM, scalenes and the sub-occipital muscles.

No, an MD won't refer you for massage if you have sinus problems or ear problems. They will refer you for physical therapy or massage if you have muscular problems, such as neck or back problems and what I am saying is that some of these patients with neck and back problems also have sinus and ear problems and at times, when I have been working with the neck and around this area generally, once the tightness in these muscles and normal length has been restored the other problems sometimes resolve or lessen in severity too.

Not all patients with neck problems actually have sinus and ear problems, but in the ones who do, once some of this muscular tightness is removed, some of the other problems do seem to get better.

This is just what I have observed in my practice of physical therapy and sports massage.

If you have sinus or ear problems, then yeah, go see an MD and if you have muscular problems, then go see or get a referral to a physical therapist rather than a chiro. You can also see a DO instead.

filippo lippi

16th May 2008, 12:11 PM

As a physical therapist and sports massage therapist, I work with musculo-skeletal problems. What I have found in my practice is that in some patients that I see who have musculo-skeletal problems also accompanied with either sinus problems or ear problems have found relief from these problems when I have worked on tight and shortened musculature in the areas of the neck and all the muscles in this area - upper traps, SCM, scalenes and the sub-occipital muscles.

No, an MD won't refer you for massage if you have sinus problems or ear problems. They will refer you for physical therapy or massage if you have muscular problems, such as neck or back problems and what I am saying is that some of these patients with neck and back problems also have sinus and ear problems and at times, when I have been working with the neck and around this area generally, once the tightness in these muscles and normal length has been restored the other problems sometimes resolve or lessen in severity too.

Not all patients with neck problems actually have sinus and ear problems, but in the ones who do, once some of this muscular tightness is removed, some of the other problems do seem to get better.

"Hearsay and conjecture are types of evidence."

As I thought, these conditions that generally get better on there own also get better when you've manipulated them, but you don't have any other proof that your manipulations have any effect.

Croydon Bob

16th May 2008, 05:33 PM

Neuromuscular Therapist

16th May 2008, 10:01 PM

"Hearsay and conjecture are types of evidence."

As I thought, these conditions that generally get better on there own also get better when you've manipulated them, but you don't have any other proof that your manipulations have any effect.

Firstly, I practice physical therapy and sports massage, so I DO NOT USE MANIPULATION as part of my practice. Chiropractors use manipulations, but I don't. Do you actually know the difference between these practices?

I use tests in my practice at the beginning and end of treatment to evaluate whether my work has been effective.

What I have put forward is not really meant to be evidence, but just what I happened to have noticed as part of my practice, in that once shortness and tightness in muscles has been released and muscular balance is achieved, some other problems that are thought to be unrelated can resolve.

That is all I am saying, no more and no less.

Graham Lappin

17th May 2008, 11:38 AM

What I have put forward is not really meant to be evidence, but just what I happened to have noticed as part of my practice, in that once shortness and tightness in muscles has been released and muscular balance is achieved, some other problems that are thought to be unrelated can resolve.

That is all I am saying, no more and no less.

Neuromuscular Therapist - I take your point that you are not trying to make any outrageous claims but very often our intuitions can be misleading - it's science that shows our instincts are not always correct. The immediate problem is that there is no known mechanism by which the ear is directly linked to musculo-skeletal system and so the claim that treating one can effect a therapy in the other immediately rings alarm bells. There can of course be indirect links, a feeling of well-being after a massage for example but that is so general it could apply to virtually anything. For a direct association to be true, it would have to overturn a lot of scientific and medical evidence, which would make it an extraordinary discovery. Extraordinary claims require extraordinary evidence and so in all likelihood, the association you see is a perception of a pattern that is not really present.

Have a look at the short clip on You Tube http://www.youtube.com/watch?v=WCW8ocazmEM just as an illustration of how the mind can see associations that are not necessarily real.

I assume from what you have said that you are not a believer in subluxations and similar?

Neuromuscular Therapist

17th May 2008, 12:54 PM

I AM NOT A CHIROPRACTOR.

I am however a physical therapist and a sports massage therapist and by definition, I work with the muskulo-skeletal system, that includes muscles and fascia.

No, I don't believe that subluxations exist.

There is an indirect link between the ear and muscles via and SCM attaching to the mastoid tip.

I know everything that you are saying - I have not been in practice for the last 20 years without learning a thing to two, but I do take notice of what my patients tell me. I do listen and this is what they have told me when they have come back after some treatments. That is all I was saying.

Graham Lappin

17th May 2008, 01:41 PM

No, I don't believe that subluxations exist

I didn't think you did but I was just checking

There is an indirect link between the ear and muscles via and SCM attaching to the mastoid tip.

Not quite what I meant. What I was saying is that there is no mechanistic reason why treatment on, for example, the gastrocnemius muscle could have a therapeutic effect on the ear. (I just use these as example to illustrate the point, by the way. I am not saying you have made such a claim).

I know everything that you are saying - I have not been in practice for the last 20 years without learning a thing to two

I think you are somewhat thin ice with this one. I have been a clinical research scientist for 25 years but speaking from this authority does not automatically make me right.

but I do take notice of what my patients tell me. I do listen and this is what they have told me when they have come back after some treatments.

This is fine as far as it goes but this is exactly what homeopaths, acupuncturist etc quote to support their beliefs. What you are saying is intuition. Many discoveries started with intuition but it is then a matter of advancing the intuition into a testable hypothesis. I am just making the point that taking this approach, it is so easy to get misled into the wrong conclusion.

That is all I was saying.

From this I take it that you have made the observation and you don't really want to extrapolate the conclusion too far, which is something we can both agree upon.

Don't drink the bongwater

2nd September 2008, 11:55 PM

Well, I am an osteopath, at least I used to be (got bored to be honest, probably a pretty poor career choice for someone like me with a low tolerance for repetition and listening to patient complaints). This discussion is pretty funny, there are quacks out there that are osteopaths, but I don't think any more than any other health professions. I think craniosacral therapy is crap and I think any chiro who thinks they can cure "disease" is fooling themselves, to put it nicely. You won't get a bigger skeptic of the manual therapy profession than me, and I actually know what I am talking about when it comes to what is dogma and what isn't and I have pretty strong viewpoints on a lot of manual therapy practice in general.

However I have to say that practicing manual therapy, when done well and applied to the right cases, is very effective, for back pain, neck pain etc. Sure there are some unscrupulous bastards, but they are, at least in my experience in osteopath circles fairly few and far between (but I can name the one that I think are dodgy). But as there are less numbers of osteopaths overall as opposed to say, GP's, a few bad apples can spoil the barrel quick smart.

Lots of what seems to work in manual therapy has inadequate evidence behind it in general. Funnily enough though, most of my lecturers at Osteo school (at least for anatomy, physiology, pathology, clinical diagnosis, neuro etc etc) were practicing MDs and I remember one of them, a well renowned GP, saying a large bulk of what the average GP does on a daily basis has pretty sketchy evidence tied to it (I believe the figure 75% was tossed about). This always struck me as pretty high, and I don't believe that is a published figure (I have searched but nada), but an interesting note from someone in the field.

It's funny how people think manual therapy professions don't know jack - I can't speak on behalf of physio's or chiros, but the osteopathic profession bases everything on conventional medical diagnosis first and foremost and in musculoskeletal examination they are highly proficient. When I was practicing, I picked up, through routine patient workup, 5 cases of various cancers that were missed by family GPs, two pretty serious cases of DVTs and a couple of other interesting bits and bobs that stuck out like dog's balls to me - but apparently not the local physician practices, not bad for a quack. Now all I did was conduct a routine history, physical and followed up with some indicated diagnostic radiology tests on the side - so I'm buggered if I know what the GP was doing. If there were cases where I couldn't figure out what was going on and help someone out pretty quickly, I referred them off to someone better equipped. O0

I hate practitioners of any kind who think they can bring peace to the middle east with a quick crack of the back. >:D

bindeweede

3rd September 2008, 12:12 AM

Ddtb,

You mentioned manual therapy several times. Could you explain in a bit more detail what that is exactly? Sorry to be tedious. You see, this confuses me...

You won't get a bigger skeptic of the manual therapy profession than me, and I actually know what I am talking about when it comes to what is dogma and what isn't and I have pretty strong viewpoints on a lot of manual therapy practice in general.

However I have to say that practicing manual therapy, when done well and applied to the right cases, is very effective, for back pain, neck pain etc.

Mongrel

3rd September 2008, 01:13 AM

DD - I accept that a minority of osteopaths and chiropractors don't follow the wackier side of things but is there anything, at the end of the day, that separates them from a good physiotherapist?

Blue Wode

3rd September 2008, 11:11 AM

Funnily enough though, most of my lecturers at Osteo school (at least for anatomy, physiology, pathology, clinical diagnosis, neuro etc etc) were practicing MDs and I remember one of them, a well renowned GP, saying a large bulk of what the average GP does on a daily basis has pretty sketchy evidence tied to it (I believe the figure 75% was tossed about). This always struck me as pretty high, and I don't believe that is a published figure (I have searched but nada), but an interesting note from someone in the field.

The following might be of interest to you:

It’s a sad moment for British medicine when the chair of the NHS Alliance, Dr M Dixon, states that ‘only 10% of what doctors do in primary care is evidence-based’.1 (http://www.medicinescomplete.com/journals/fact/current/fact0902a09n06.htm#fact0902a09n06b0001) The actual evidence shows that the figure is around 80%!2 (http://www.medicinescomplete.com/journals/fact/current/fact0902a09n06.htm#fact0902a09n06b0002) But even if the 10% figure were correct, this would not lend itself, as Dr Dixon does, to the integration of more unproven treatments into the NHS. We first need to ensure that a therapy generates more good than harm and only subsequently should we consider it for general use. This course of action is not ‘integrated medicine’ but follows the principles of ‘evidence-based medicine’.http://www.medicinescomplete.com/journals/fact/current/fact0902a09n06.htm (http://www.medicinescomplete.com/journals/fact/current/fact0902a09n06.htm)

In recent years the claim that only 20% or less of standard Western medicine is evidence-based has been repeated widely by health professionals and others. [1]

This assertion is perhaps most often made by proponents of unproven (‘alternative’ and ‘complementary’) therapies with the implication that, if true, it might somehow justify the integration of any number of unconventional modalities with a similar dearth of supporting scientific evidence into main-stream medical practice.

It should be immediately noted that this line of reasoning is an example of the logical fallacy tu quoque (‘you did it too’): one party cannot criticize another because both parties are guilty of the same ‘sin.’ While this argument may be without merit, it is often made and widely held to be valid. Therefore, the authors of this paper have attempted to identify the sources of, and examine the evidence for, the ‘20% or less’ claim.

-snip-

In 1991, Dr David Eddy, at a conference in Manchester, UK, claimed that only 15% of medical practice was based on any evidence at all. He apparently based this sweeping conclusion entirely on his studies of treatments for just two specific conditions: arterial blockage in the legs and glaucoma.[10] Subsequently, Dr Eddy’s claim, rather than the much more conservative OTA ‘armchair estimate,’ has been widely cited as a criticism of mainstream medicine.

-snip-

Regardless of the origin or intent of the original assessments, critics of the ‘10 to 20%’ claims were originally unable to refute them because no solid evidence existed either in favor of or against them. That situation has changed in recent years. A growing body of evidence now exists regarding the extent to which medical practice is evidence-based.

-snip-

Evidence for evidence-based practice includes those listed in the box (q.v.).

• 96.7% of anesthetic interventions (32% by RCT, UK)[13]
• approximately 77% of dermatologic out-patient therapy (38% by RCT, Denmark)[14]
• 64.8% of ‘major therapeutic interventions’ in an internal medicine clinic (57% by RCT, Canada)[15]
• 95% of surgical interventions in one practice (24% by RCT, UK)[16]
• 77% of pediatric surgical interventions (11% by RCT, UK)[17]
• 65% of psychiatric interventions (65% by RCT, UK)[18]
• 81% of interventions in general practice (25.5% by RCT, UK)[19]
• 82% of general medical interventions (53% by RCT, UK)[20]
• 55% of general practice interventions (38% by RCT, Spain)[21]
• 78% of laparoscopic procedures (50% by RCT, France)[22]
• 45% of primary hematology–oncology interventions (24% by RCT, USA)[23]
• 84% of internal medicine interventions (50% by RCT, Sweden)[24]
• 97% of pediatric surgical interventions (26% by RCT, UK)11
• 70% of primary therapeutic decisions in a clinical hematology practice (22% by RCT, UK)[25]
• 72.5% of interventions in a community pediatric practice (39.9% by RCT, UK)[26]

More…
The evidence for evidence-based medicine Complementary Therapies in Medicine (2000), 8, 123–126

http://www.veterinarywatch.com/CTiM.htm (http://www.veterinarywatch.com/CTiM.htm)

Mojo

3rd September 2008, 02:16 PM

I think any chiro who thinks they can cure "disease" is fooling themselves, to put it nicely. You won't get a bigger skeptic of the manual therapy profession than me, and I actually know what I am talking about when it comes to what is dogma and what isn't and I have pretty strong viewpoints on a lot of manual therapy practice in general.

However I have to say that practicing manual therapy, when done well and applied to the right cases, is very effective, for back pain, neck pain etc. Sure there are some unscrupulous bastards, but they are, at least in my experience in osteopath circles fairly few and far between (but I can name the one that I think are dodgy). But as there are less numbers of osteopaths overall as opposed to say, GP's, a few bad apples can spoil the barrel quick smart.

What do you think of the GOsC's (http://www.osteopathy.org.uk/about_osteo/Babies_Children.pdf) claims that osteopathy can treat ear infections and asthma, among other conditions, and "help children suffering from cerebral palsy or Down's Syndrome"?

Don't drink the bongwater

3rd September 2008, 02:46 PM

Ok, manual therapy - general term for all who practice anything with a hands-on-body application (either massage, manipulation etc). It's a way to throw everyone in the same bucket from one respect, which is valid because there is overlap in the execution of some of the techniques.

I have to take exception with: "I accept that a minority of osteopaths and chiropractors don't follow the wackier side of things" as grossly inaccurate (of osteopaths) in my experience. I'd actually argue in the opposite direction that most of the osteopaths I know are legit and working hard to help people, making care-based decisions. Yeah, sure I know some whose practice decisions are driven by cash first (I can name them on one hand), and I think they undeservingly give everyone a shitty reputation.

What separates an Osteopath from a good physio you ask? (I'm conveniently ignoring the chiro side of things because I wasn't one)
Well, there are similarities and differences and it is not cut an dried. One way of explaining - that is bound to piss some people off, though I long ago stopped caring about who I offend on this matter - is the level of diagnostic ability. Physios are good at recognizing musculoskeletal problems, osteos are historically rooted in being medical practitioners (in the US) and this has most certainly filtered through to today's osteopath. Knowledge of pathology, clinical diagnosis, lab diagnostics and radiology is heavily emphasized, which means that not only can many of them figure out what they are treating, but more importantly they can figure out what they shouldn't treat, and to refer these people to the appropriate specialty. This is also the biggest problem with osteopathy as a profession IMO, as you know what you are dealing with in many cases, but can't do a damn thing about it (which is still better than the chiros who purport to cure "disease" my manipulating a subluxation if you ask me) - making you realize you should either go back to medical school or just have remained blissfully unaware and gone into finance and law in the first place. Bottom line to ask yourself: are you happy with the service you get from your physio? If so, keep it up.

O0

Don't drink the bongwater

3rd September 2008, 03:41 PM

What do you think of the GOsC's claims that osteopathy can treat ear infections and asthma, among other conditions, and "help children suffering from cerebral palsy or Down's Syndrome"?

The problem with this claim is the broadness of the statement leading to the resulting interpretation. Saying you can "treat" something versus "cure" is radically different. I don't think they are being irresponsible by stating they can effectively treat these conditions. Especially since there is evidence indicating positive outcomes. Personally, I never treated anyone for asthma or inner ear infections because I liked sticking to more "nuts and bolts" neck and back pain cases. However some do and I have seen some pretty good results. As I mentioned before I largely think craniosacral technique is bollocks (and I am not alone on this: ptjournal.org/cgi/content/full/82/11/1146) and most studies I have read on it indicates dodgy inter and intra-examiner reliability, which is not a good sign for those who profess it is the "bees knees".

I'm not going to try to sway you one way or the other, there is a bunch of lit out there, read it all and make up your own mind, however to give you an example of studied efficacy of osteopathic treatment on asthma - Check out this abstract from a 2005 RCT in the Journal of the American Osteopathic Association Guiney et al. 105 (1): 7. (2005):

"Asthma is a common chronic condition that has long plagued the pediatric patient population. Asthma in children can cause excessive school absenteeism, hospitalizations, and even death. Osteopathic manipulative treatment (OMT) is an underutilized noninvasive treatment method for patients with asthma. The use of OMT may help decrease mortality and morbidity rates among this patient group. The authors conducted a randomized controlled trial attempting to demonstrate the therapeutic relevance of OMT in the pediatric asthma population. With a confidence level of 95%, results for the OMT group showed a statistically significant improvement of 7 L per minute to 9 L per minute for peak expiratory flow rates. These results suggest that OMT has a therapeutic effect among this patient population. The authors suggest that more clinical trials are required to better demonstrate the effectiveness of OMT in patients with asthma."

Who really knows what the mechanism of action is. You want to tell me you can isolate from an externally applied technique whether the effect on improved respiration is due to improving rib motion, as distinct from having some sort of effect on the nervous system or a host of other potential effects? The outcome in this study indicated a positive effect, and I'll bet if you have asthma, and this makes you feel better, you're pretty happy that you did it. However, for a practitioner to say with any degree of certainty that this reduces bronchoconstriction or inflammation in the air passages, would be wrong, but then again I don't know any practitioner personally who does that. Let's see some more good studies before we make any overly outlandish claims or write it off though eh?

For inner ear infections I'm way less confident on the benefit, but thats my inner skeptic - if you are talking about promoting fluid drainage through the eustachian tubes, for a short term symptomatic relief, then sure maybe you can have some sort of effect. There has also been some research on this in a 2003 archives of pediatrics and adolescent medicine journal.

The conclusion: The results of this study suggest a potential benefit of osteopathic manipulative treatment as adjuvant therapy in children with recurrent AOM; it may prevent or decrease surgical intervention or antibiotic overuse.

But you and I both know pretty well, if you get an infection the body can't overcome on it's own, you're going to need some antimicrobials sooner or later, however the results indicate it's probably not all complete garb ;)

Sorry I can't post the links - apparently I need 15 posts before I'm allowed to do that

Pebble

3rd September 2008, 10:04 PM

Dont drink the bogwater:

The study is nonsense!

Peter A. Guiney, Rick Chou, Andrea Vianna, and Jay Lovenheim
Effects of Osteopathic Manipulative Treatment on Pediatric Patients With Asthma: A Randomized Controlled Trial
J Am Osteopath Assoc, Jan 2005; 105: 7 - 12.

The errors are simple, but any decent reviewer would have spotted them.
First this is an unblinded comparison of OMT to an allopath placing hands on - very different levels of 'placebo' efficacy. Second there is no theoretical basis. The stats are flawed.

Table 2 Peak Expiratory Flow Rates for Pediatric Patients with Asthma Before and After Treatment Protocols (Liters per Minute)

Osteopathic Manipulative Treatment Group (n=90) Control Group (n=50)

Pretreatment 364 (150 ) 319 (130 )
Posttreatment 377 (148 ) 320 (123 )
Difference 13 (27) 0.3 (36)

The authors chose to look only at the differences in readings and to calculate confidence intervals from here. Thus for a population of 90 a difference of 13 litres in 90 patients with a standard deviation of 27 entered incorrectly into a calculating machine gives a CI of 7.42 - 18.58. The assumption being that the standard deviation of the population is the standard deviation of the difference.

However, the T test should have compared the peak flows before and after each treatment (paired t testing).

Thus, the mean and confidence interval before intervention was 364 (CI 333 - 394.9 ) and after 377 (CI 346.4 - 407.58 ) the confidence intervals greatly overlap because of the large variability of the population results.

Therefore the correct interpretation is that OMT had no measurable effect, and was no different to the comparator.

This is easily seen from the associated graph of the differences where the bell shape curve clearly extends well beyond the zero difference line.

http://www.jaoa.org/content/vol105/issue1/images/large/Page10fig1.jpeg

Don't drink the bongwater

3rd September 2008, 11:31 PM

Pebble, firstly, it's BONGWATER. I'm not drinking liquid from a toilet! >:-)

I'm glad you read the study, because I just threw it out there to see if people around here actually do, and it's that level of scrutiny that needs to be applied to papers. Secondly, your stats knowledge is pretty good so kudos...Even without looking closely at the numbers, the level of control is dodgy because you ideally need to control the practitioner administering the osteopathic treatment also. Allopathic has no idea and would be way different, so it doesn't fly

Can you give me your opinion on the ear study also...curious to hear as I just posted that but haven't even read it.

Secondly, just to note, I never said it was a high quality piece of lit, if you'll read carefully through my piece you will note that the closest I got was "Let's see some more good studies before we make any overly outlandish claims or write it off though eh?" (Which is not praising this paper, but asking for more, good studies" (although leaving the comma out I could see where the misinterpretation could occur).

So even if the study is shite, it doesn't prove anything conclusively, except that the study is shite. Not that osteopathy is effective or ineffective. Lack of evidence doesn't mean evidence of lack. You'd need a battery of studies to make any argument and they are not available. Fancy doing a few? I sure as hell have more interesting things to do now.....

Biggest thing I think complementary professions suffer from is there is
a. a paucity of people conducting research due to lack of funding
b. no big bucks to be made so big pharma and med device companies are not sponsoring stuff like they do in medical research
c. probably a lack of qualified personnel in the past (although this is changing as complementary therapies get into the univeristy system)

Although I should point out - this study was conducted in a US hospital - where DO is equivalent to MD - demonstrating that even regular medics are crappy at research too.

here's some more manipulation related lit on asthma, say more evidence required: http://www.cochrane.org/reviews/en/ab001002.html

and check out this in the "effectiveness" section: http://en.wikipedia.org/wiki/Osteopathic_manipulative_medicine

Mojo

3rd September 2008, 11:40 PM

Here's a link to the text of the asthma paper:
http://www.jaoa.org/cgi/content/full/105/1/7

I'm not going to try to sway you one way or the other, there is a bunch of lit out there, read it all and make up your own mind...
I had a quick look on pubmed for "osteopathic" or "osteopathy" and "asthma", and found that others have already done this in a Cochrane review published a few months after that trial:

http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001002/frame.html

There is insufficient evidence to support the use of manual therapies for patients with asthma.

I couldn't find any more recent trials of osteopathy for asthma.

Don't drink the bongwater

3rd September 2008, 11:51 PM

Yep that's the same content as what I posted above. Good find.

Pebble

4th September 2008, 07:21 AM

Dont drink the Bongwater (why that?)

Ear infections:

6 Clinical trials in Pubmed, 5 with antibiotics, 1 osteopathy.

http://archpedi.ama-assn.org/cgi/content/full/157/9/861#TABLEPOA20402T1

Better design and stats.

Statistical calculations based on some unpublished dissertation work of one of the authors. Planned 50% reduction in antibiotic prescription for recurrent ear infections (achieved 17% - not significant), but planned recruitment of 120 subjects with 60/40 randomisation to ensure 50 in each group - however ended up analysing 57 patients of 146 screened.

Single blind trial - patients and parents not blinded.

Groups un matched - more cigarette exposure in control group 22% v 4%

Outcome: per protocol only (no intention to treat analysis)

No improvement in objective measures (some favorable trends)

Reduction in several measures of 'ear infections' at borderline significance levels.

Conclusion:

Negative trial (failed to meet primary endpoint)

Single blind - only measures showing positive outcomes were aspects that are succeptible to placebo effect.

Per protocol analysis only (favors larger treatment effect)

Don't drink the bongwater

4th September 2008, 02:22 PM

Dont drink the Bongwater (why that?)

Nothing more amusing than seeing "Welcome, Don't drink the bongwater" when I sign in ;D

Don't drink the bongwater

7th September 2008, 09:23 PM

Well, this conversation went quiet really quickly.

I'd like to add something regarding the validity of most clinical studies of manual therapy to osteopathy (as distinct from traditional chiropractic treatment) to give you all something to think about. I know basically no osteopath, who treats with manipulation only (defining manipulation as the typically thought of "twist and crack" type event that many associate with a visit to such a practitioner. In fact, the level of deep soft tissue used is significant, if not a large majority of a 30-60 minute consultation. Therefore, how is the applicability of these studies that don't clearly define what manipulation is, render them at all relevant? therefore don't be so quick to lump all manipulation studies together and apply the results broadly across a population of diverse practitioners, where some practitioners give a 5 min "crack" (you know who you are out there) vs those that use other techniques. If the treatment is not well defined in a study, this is yet another issue take in terms of study quality.

Secondly, how do you then separate the component of deep soft tissue "massage" type work as distinct from the manipulative "crack" when many studies don't assess this? There is a lot of work to yet be done before the picture becomes clear in this area of treatment.

Studies that assess high velocity techniques only are fairly redundant in terms of inferring anything about quality of care or efficacy of treatment, because any practitioner with half a brain already figured out pretty quick that this type of treatment is about as useful as whistling dixie.

Pebble

7th September 2008, 11:16 PM

Neuromuscular Therapist

8th September 2008, 09:54 AM

Unfortunately the 'massage' element has suffered a major recent setback, as for positive empirical evidence this is lacking.

http://www.bmj.com/cgi/content/abstract/337/aug19_2/a884

I don't really think that you can make a sweeping statement like this on evidence such as this!

It does not actually state what kind of massage was used - there are different types. If it was Swedish massage that is most often used as a relaxation massage or for the 'feel good factor', then this is less likely to be successful than someone who uses Sports and Remedial Massage. Sports and Remedial Massage offers a range of different techniques to help decrease pain. There is also education about stretching, exercise and movement. A lot of the soft tissue techniques used by sports massage therapists come from osteopathy.

Perhaps if that study had compared Alexander Technique lessons with Sports and Remedial Massage, rather than just their ill defined 'Massage', then the results might have been totally different.

Think about it!!

Acleron

8th September 2008, 10:46 AM

I don't really think that you can make a sweeping statement like this on evidence such as this!

It does not actually state what kind of massage was used - there are different types. If it was Swedish massage that is most often used as a relaxation massage or for the 'feel good factor', then this is less likely to be successful than someone who uses Sports and Remedial Massage. Sports and Remedial Massage offers a range of different techniques to help decrease pain. There is also education about stretching, exercise and movement. A lot of the soft tissue techniques used by sports massage therapists come from osteopathy.

Perhaps if that study had compared Alexander Technique lessons with Sports and Remedial Massage, rather than just their ill defined 'Massage', then the results might have been totally different.

Think about it!!
In your opinion, what is the best evidence that Sports and Remedial Massage is useful?

Pebble

8th September 2008, 07:21 PM

I don't really think that you can make a sweeping statement like this on evidence such as this!

[snip]

Perhaps if that study had compared Alexander Technique lessons with Sports and Remedial Massage, rather than just their ill defined 'Massage', then the results might have been totally different.

Think about it!!

This study indeed included a massage therapy arm, however physiotherapists have been very active in studying the benefits or lack thereof of their interventions, have you compared the available database on physiotherapy to sports massage in properly conducted, randomised trials?

Neuromuscular Therapist

8th September 2008, 07:35 PM

This study indeed included a massage therapy arm, however physiotherapists have been very active in studying the benefits or lack thereof of their interventions, have you compared the available database on physiotherapy to sports massage in properly conducted, randomised trials?

Not yet, but I will be doing so, as physical therapists do not usually use massage as a modality in their practice.

Don't drink the bongwater

8th September 2008, 10:40 PM

That study once again is not applicable if you ask me because - because anyone worth their salt will incorporate more than just one type of therapy, some soft tissue massage, maybe manipulation if deemed appropriate, with pilates, other exercise, or simply stretching instruction - seeing that is "real world" treatment we need to study more real world situations.

However let's play devil's advocate here for a minute - maybe we should throw the baby out with the bathwater. being the skeptic that I am if it is all proven to be crap in the end, (massage, chiropractic, physiotherapy, osteo etc and anything similar) then manual therapies deserve to be banned outright. It's the only logical pursual of this conversation. Why not? It's a waste of public money if it is not effective therapy. Then when people get sore necks and backs they can shut-up and put up with it, go see a psychiatrist or psychologist or better yet maybe the government will finally allow people to go get some effective dose OTC medications to manage it themselves. Who's got the balls to lead that charge? Let's make sure we equitably squash everything else that is rubbish on the way, including ineffective, non-evidence based medical therapies.....

The problem with manual therapy is that no matter what you know regarding evidence, as a practitioner you are going to do the same thing because you have a limited scope of practice. There is no technology coming to help you out and you can't administer medicine or do surgery. So anyone in a manual therapy will cling tightly to their techniques as a holy grail. having said that I still think it is worth a full exploration to see exactly how beneficial it really is and this is a long way off.

Here's another manipulation RCT comparing osteopathic manipulation with conventional medical care. Only difference was less medication required by patients in the non-maniplation group. However at least it replicated a real world situation "A variety of techniques were used, including thrust, muscle energy, counterstrain, articulation, and myofascial release. The treating physician chose the techniques used."

Pebble, care to tear apart the statistical component for the readers?

Pebble

9th September 2008, 06:43 AM

Need a little more detail on the trial - authors, title or even year.

Generally trials should be designed to compare no more than two therapies. Any more and the statistics won't work, further one always has differences in opinion as to what element caused ones favored approach to fail. It is possible to compare 'conventional' with 'alternative' but the osteopaths will say the chiros let them down, the chiros will blame the homeos etc. The trick is to choose a problem at which two groups believe or has supportive evidence for their particular technique/approach/intervention and to limit the study to that given group.

Neuromuscular Therapist

9th September 2008, 10:22 AM

That study once again is not applicable if you ask me because - because anyone worth their salt will incorporate more than just one type of therapy, some soft tissue massage, maybe manipulation if deemed appropriate, with pilates, other exercise, or simply stretching instruction - seeing that is "real world" treatment we need to study more real world situations.

I completely agree. In my practice I use more than just one mode. In my practice I regularly use MET (Muscle Energy Technique), STR (Soft Tissue Release), Myofascial Release, Strain, Counter strain, Positional Release and Neuromuscular Technique, which is working to locate and de-activate Trigger Points. I use a mixture of techniques, according to the client in front of me, what their problem is and their needs.

[QUOTE=The problem with manual therapy is that no matter what you know regarding evidence, as a practitioner you are going to do the same thing because you have a limited scope of practice. There is no technology coming to help you out and you can't administer medicine or do surgery. So anyone in a manual therapy will cling tightly to their techniques as a holy grail. having said that I still think it is worth a full exploration to see exactly how beneficial it really is and this is a long way off.
[/QUOTE]

I don't quite see how manual therapy has a limited scope of practice? Yes, if you are doing manual therapy, then you are not performing surgery, however, within the scope of manual therapy there are lots of techniques that can be used - massage, deep tissue massage, myofascial release, soft tissue release, Trigger Point work, muscle energy technique, positional release, stain/counter strain, exercise advice, stretching, facilitated stretching and postural assessment.

Pebble

9th September 2008, 12:53 PM

Neuromuscular Therapist

9th September 2008, 04:26 PM

[
Nice terms: do they simply describe what you do, or the impact in the body, if the latter any evidence base? How do you know that the muscle energy technique does something to the metabolism of the muscle, if so what how much, for how long etc?

Oh, sorry, but I thought you came here claiming to know something about osteopathy or osteopathic practice? Evidently I was wrong in my assumptions!! A lot of the techniques that I have mentioned are used routinely by osteopaths as part of their soft tissue work. They are also used regularly in sports massage practice and yes, there is an evidence base to back them up.

The aim of MET is firstly to inhibit the muscle and then to lengthen it so that you can then achieve more movement.

The aim of any manual therapy should be to locate short and tight muscles and use techniques/methods to lengthen them. Short and tight muscles will cause pain, so when the muscles are then lengthened the pain will be reduced because an overall muscular balance has been achieved.

Don't drink the bongwater

9th September 2008, 06:18 PM

All different ways to poke, prod, press and stretch. Only theorized mechanisms of action and no particularly strong evidence as yet that any is more effective in a particular condition than another, but one again they are typically performed in concert with other techniques, so those studies would be practically worthless if done.

Pebble

9th September 2008, 11:10 PM

Oh, sorry, but I thought you came here claiming to know something about osteopathy or osteopathic practice? Evidently I was wrong in my assumptions!!

Can't imagine where you got that idea. I am questioning the strength of evidence not claiming to be a practitioner. I am not a mechanic, but before I buy a car I want to know what it does, and whether it is better than the alternatives, ideally with independently verifiable data. The same holds for osteopathy or any other 'treatment'. Descriptions of what you believe you are achieving are fine, but not evidence.

Acleron

10th September 2008, 12:43 AM

Can't imagine where you got that idea. I am questioning the strength of evidence not claiming to be a practitioner. I am not a mechanic, but before I buy a car I want to know what it does, and whether it is better than the alternatives, ideally with independently verifiable data. The same holds for osteopathy or any other 'treatment'. Descriptions of what you believe you are achieving are fine, but not evidence.
Quite clear, and perhaps nobody saw my question.

In your opinion, what is the best evidence that Sports and Remedial Massage is useful?
Is there any evidence, apart from the fact you do it, and it might be an inconvenience to you and your patient if you do not have any evidence for the treatment?

Pebble

10th September 2008, 07:21 AM

A lot of the techniques that I have mentioned are used routinely by osteopaths as part of their soft tissue work. They are also used regularly in sports massage practice and yes, there is an evidence base to back them up.

Any chance of sharing some of this evidence, as requested by:

Quite clear, and perhaps nobody saw my question.

Is there any evidence, apart from the fact you do it, and it might be an inconvenience to you and your patient if you do not have any evidence for the treatment?

and

How do you know that the muscle energy technique does something to the metabolism of the muscle, if so what how much, for how long etc?

and

... have you compared the available database on physiotherapy to sports massage in properly conducted, randomised trials?

Don't drink the bongwater

10th September 2008, 06:06 PM

Is there any evidence, apart from the fact you do it, and it might be an inconvenience to you and your patient if you do not have any evidence for the treatment?

Only un-scientific evidence I have for sports massage is that when I get sore legs or sore lower back and get a massage it feels great and I feel reduced (and many time completely absent) discomfort afterward. Until I go do something crazy and mess it up again, which happens a lot.

By the way Pebble, are you in the market for a therapist of some sort - I figured with the car analogy you might be hinting you have a niggle that needs tending to?
Based on that comparison, I'd really rather own a Honda or Toyota than a Jaguar considering reliability, but I bet someone with a far bigger wallet would think differently about the whole situation. In the end the market will decide and vote with their feet......

It might be a good opportunity to go for a "test drive" and then you can report back the experiences. Only thing is they tend not to give out free samples ;)

Pebble

10th September 2008, 08:34 PM

By the way Pebble, are you in the market for a therapist of some sort - I figured with the car analogy you might be hinting you have a niggle that needs tending to?
Based on that comparison, I'd really rather own a Honda or Toyota than a Jaguar considering reliability, but I bet someone with a far bigger wallet would think differently about the whole situation. In the end the market will decide and vote with their feet......
;)

Sorry to disappoint, but as the evidence base that I have been able to access supports the Alexander technique, then physiotherapist guided exercise then simple analgesia - I have enough to be getting on with.

As for the cars, how one chooses the best may vary and indeed the depth of the pocket may be a deciding factor, but that does not mean that on any given parameter one cannot compare - e.g. social kudos.

Acleron

11th September 2008, 12:46 AM

Only un-scientific evidence I have for sports massage is that when I get sore legs or sore lower back and get a massage it feels great and I feel reduced (and many time completely absent) discomfort afterward. Until I go do something crazy and mess it up again, which happens a lot.

I was advised to have a massage after strenuous exercise and felt worse. My conclusion was that anecodotal evidence is worthless. But if you have evidence for your conclusions, please supply it. Don't waste your time with anything else, just supply the most convincing evidence you have.

By the way Pebble, are you in the market for a therapist of some sort - I figured with the car analogy you might be hinting you have a niggle that needs tending to?
Based on that comparison, I'd really rather own a Honda or Toyota than a Jaguar considering reliability, but I bet someone with a far bigger wallet would think differently about the whole situation. In the end the market will decide and vote with their feet......

It might be a good opportunity to go for a "test drive" and then you can report back the experiences. Only thing is they tend not to give out free samples ;)
Oh dear, a train wreck coming soon.

Don't drink the bongwater

11th September 2008, 11:59 PM

Acleron

12th September 2008, 12:52 AM

Seeing we like to cut to the pleasantries around here:

Here's another approach I used to find highly useful - the centralization principles of Robin McKenzie - there's more than a little bit of lit supporting this idea too. Best of all you can teach people and they can help themselves...

http://www.mckenziemdt.org/libResearchList.cfm?section=int

OK, I made an assumption that the best evidence would be cited. Your ref lists 35 refs each less than an abstract. So searching for the first ref I find: Overview Supportive Studies: McKenzie Method of Mechanical Diagnosis and Therapy (MDT) (http://www.spineuniverse.com/displayarticle.php/article680.html). This is also a paper that has ten refs, none of which gives any real data. The idea of asking for your best evidence was so that we could discuss that evidence. Out of all those refs, could you supply one that is published in a reasonable journal and supports, say, the McKenzie method.

Pebble

12th September 2008, 06:53 AM

Here's another approach I used to find highly useful - the centralization principles of Robin McKenzie - there's more than a little bit of lit supporting this idea too. Best of all you can teach people and they can help themselves...

http://www.mckenziemdt.org/libResearchList.cfm?section=int

Thanks for this. Quite a bit to work through, so I will probably bite off just one section to try and get the original information to report back on. Superficially, the impression is of little evidence of signficant benefit from the better conducted trials, but general support for the exercise/posture based approach rather than passive (massage) approach.

Don't drink the bongwater

12th September 2008, 06:43 PM

OK, I made an assumption that the best evidence would be cited.

I'll save you the trouble.

Spine. (http://javascript%3Cb%3E%3C/b%3E:AL_get%28this,%20%27jour%27,%20%27Spine.%27%2 9;) 2006 Apr 20;31(9):E254-62.

The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach.

Machado LA (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Machado%20LA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), de Souza MS (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22de%20Souza%20MS%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Ferreira PH (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ferreira%20PH%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus), Ferreira ML (http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Ferreira%20ML%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsP anel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
Universidade Federal de Minas Gerais, Belo Horizonte, Brazil. lmac3689@mail.usyd.edu.au
STUDY DESIGN AND OBJECTIVES: Meta-analysis of randomized controlled trials to evaluate the effectiveness of the McKenzie method for low back pain (LBP). SUMMARY OF BACKGROUND DATA: The McKenzie method is a popular classification-based treatment for LBP. The faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials. METHODS: MEDLINE, EMBASE, PEDro, and LILACS were searched up to August 2003. Two independent reviewers extracted the data and assessed methodologic quality. Pooled effects were calculated among homogeneous trials using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie. RESULTS: Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up. Heterogeneity prevented pooling of studies on chronic LBP as well as pooling of studies included in the sensitivity analysis. CONCLUSIONS: There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.

BTW, shall I pdf all papers in future and deliver them to your inbox or do you deem references acceptable? I'd have assumed going with the systematic reviews first was obvious....

Try this link: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W7P-4RFK1D1-P&_user=607013&_coverDate=02%2F29%2F2008&_rdoc=20&_fmt=full&_orig=browse&_srch=doc-info(%23toc%236632%232008%23999919998%23677616%23F LA%23display%23Volume)&_cdi=6632&_sort=d&_docanchor=&_ct=36&_acct=C000031523&_version=1&_urlVersion=0&_userid=607013&md5=7589e861c80b634e62617754529d2b3a

Pebble

12th September 2008, 08:27 PM

Don't drink the Bongwater,

Thanks for those links, save the trouble of going through the background data, which was rather tedious as the original link mixed many articles of variable quality together. In the same issue is an excellent overview of the evidence base for all the therapies discussed, and I have to say it is quite depressing, some evidence of superiority here and there but all much of a muchness I think with one or two clear rubbish approaches.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W7P-4RFK1D1-17&_user=10&_coverDate=02%2F29%2F2008&_rdoc=35&_fmt=high&_orig=browse&_srch=doc-info(%23toc%236632%232008%23999919998%23677616%23F LA%23display%23Volume)&_cdi=6632&_sort=d&_docanchor=&view=c&_ct=36&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=e5925d08a8b3f1505ca60e76fd9fcdb0

Acleron

13th September 2008, 01:15 AM

CONCLUSIONS: There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.

BTW, shall I pdf all papers in future and deliver them to your inbox or do you deem references acceptable? I'd have assumed going with the systematic reviews first was obvious....
My bolding.
Please no, if that's the best you have, the rest is not needed. Thanks for the info, I'm sure you agree that the person making the claims should supply the evidence.

davidrodway

28th February 2009, 08:14 PM

Hi
Just joined. So you know who I am, I am a British osteopath, qualified from the BSO in 1979. I have recently become aware of Howard Beardmore and the BIM, and have crossed swords with him on the forum Osteopathy For All. I think he would admit that - to his great displeasure - his views, and those of a small number of osteopaths who agree with him - do not refect those of the vast majority of osteopaths in britain. He is a follower of a now deceased osteopath John Wernham, who ran a very small osteopathic college in Maidstome (not to be confused with the ESO, also in Maidstome).

If you want to get a flavour of the a more mainstream osteopathy, can I humbly suggest a visit to the site of the South wales Osteopathic Society (google osteopathy, south wales). No doubt there will be peices of this with which you might take issue, but I think it gives a better picture of the way modern day osteopaths are thinking.Better to be criticised for what you think than what you don't

Dubious Dick

28th February 2009, 08:26 PM

davidrodway,

Out of interest, what is your view of cranial osteopathy for babies and young children supposedly suffering all sorts of symptoms e.g. colic etc because it is claimed, I believe, that their vertebrae are out of alignment from awkward birth?

davidrodway

28th February 2009, 10:48 PM

Thats not quite the osteopathic position . I beleive it is the chirpractors view that upper cervical problems can occur during birth and can cause colic.

The "cranial" osteopathic view is different and possibly weirder. I should say that not all osteopaths use the "cranial" approach - probably the majority do not - and that even among those that do it is recognised that that traditional (Sutherland) explanation for how it works is unlikely.

"Cranial" osteopathy was originally based on the premise that there is a very small degree of movement between the sutures of the skull, even in the adult. Palpation of this movement by the osteopath and techniques to restore normal mobility are held to yeild diverse health benefits.

In babies, esp those who have undergone a difficulkt birth - eg forceps delivery - cranial osteopathy seems to have helped in some conditions, such as "colic".

There is some research (see the wensite) that appears to support this, However, it was done with the parents present in the treatment room , so of course some sort of placebo effect (on the parents and then back to the baby) cannot be ruled out.

Of "cranial" generally, I think it fair to say that the theory behind it, in my veiw at least, is very suspect, but the results are often intriguing.

I think the osteopathic profession as a whole may be struggling towards an explanation of how "cranial" osteopathy works. Osteopaths who use a lot of "cranial" claim to get impressive results - the profession is trying to get a proper research effort (see the south wales osteopathy website again) developed to see whether anecdote translates to real statistical effect. In "cranial" we may well have a real effect that as yet lacks a convincing explanation.

Pebble

1st March 2009, 03:42 PM

imm0rtalmask

1st March 2009, 07:36 PM

It’s really quite worrying

davidrodway

2nd March 2009, 12:22 AM

Pebble

2nd March 2009, 06:44 AM

I dont think i used the word "amazing".

Apparently i am not yet allowed to put on here the actual website address, but if you google osteopathy+south wales you should find the website of the south wales osteopathic society. On the websites A to Z you should find research under R, or type it into Search. You can also type in colic.

The cranial osteopath view is explained more fully on their website -try Osteopath+Sutherland Society (i am not a member)

You are right you wrote "impressive" but it would be truly amazing if the results were impressive.

The cranial osteopaths opinion of themselves is of no interest, the published research or the published reviews based on analysis of the evidence is - for example:

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=16762070

"This treatment regime lacks a biologically plausible mechanism, shows no diagnostic reliability, and offers little hope that any direct clinical effect will ever be shown. In spite of almost uniformly negative research findings, "cranial" methods remain popular with many practitioners and patients."

davidrodway

2nd March 2009, 07:46 AM

Sorry, perhaps I wasnt clear enough.

The website I refer to in my second paragraph is that of the South Wales Osteopatic Society. There is a page on there relating to Research in osteopathy in general. and allied subjects - some of it carried out by osteopaths , some by others. It is not a website about "cranial", although there are some references to it.

The website mentioned in the last paragraph is purely cranial. I have not visited it recently - they may well have objective research on there.

Blue Wode

3rd March 2009, 06:54 PM

Hello David, and welcome to the UK Skeptics forum. :smiley:

British scientists, Simon Singh and Edzard Ernst, devote a page (305) of their book, Trick or Treatment? Alternative Medicine on Trial, to craniosacral therapy/cranial osteopathy (they don’t differentiate between the two). They say that despite the brevity of the section, they have rigorously examined the scientific evidence for and against it in order to reach their conclusions:

The little research that exists fails to demonstrate the craniosacral therapy is effective in treating any condition. Moreover, therapists struggle to give consistent diagnoses for the same patient, probably because they are attempting to detect a non-existent phenomenon. Mothers bringing their children to a therapist are sometimes impressed by the positive reaction. This is likely to be a relaxation response caused by the gentle touch and calming manner of the therapist, but these effects are usually short-lived. There are no conceivable risks, but if severely ill children are treated with craniosacral therapy instead of an effective treatment, the approach becomes life threatening.

Conclusion
There is no convincing evidence to demonstrate that craniosacral therapy is effective for any condition. Prolonged treatment series are expensive and unnecessary.
And for osteopathy, on p321, they conclude:

The evidence that the osteopathic approach is effective for treating back pain is reasonably sound. If, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercise, which is backed by similar evidence and which can be done in groups and therefore is more cost-effective. There is no evidence to support osteopathy for the treatment of non-musculoskeletal conditions.

BTW, here’s your link to the South Wales Osteopathic Society:
http://www.osteopathywales.com/ (http://www.osteopathywales.com/)

Some of the information on its index page seems to be inconsistent with Singh and Ernst’s findings:

Osteopaths use hands-on manual techniques to treat patients with a wide variety of conditions arising from or affected by the musculo-skeletal system.

These conditions can include…tinnitus, sinusitis…irritable bowel syndrome, glue ear, colic...

Would you please post the link to the General Osteopathic Council’s Code of Practice so that we can see what it says about osteopaths’ provision of care and evidence. Thanks.

Neuromuscular Therapist

4th March 2009, 08:20 AM

You can find the General Osteopathic Council's website at www.osteopathy.org.uk

Practice guidelines are posted down the bottom of the first page.

filippo lippi

4th March 2009, 11:43 AM

Waves at our sometime resident hit and run friend of the homeopath!

I've a bit of sinus trouble at the moment, what neck muscles should I be massaging to cure myself?

Blue Wode

4th March 2009, 06:10 PM

You can find the General Osteopathic Council's website at www.osteopathy.org.uk (http://www.osteopathy.org.uk)

Practice guidelines are posted down the bottom of the first page.
Thank you for that, Neuro.

Having read through the General Osteopathic Council’s Code of Practice, it mentions the word ‘evidence’ only once, and that’s in the section addressing insolvency. The closest reference to evidence-based practice seems to be in section 8:

UNDUE INFLUENCE ON PATIENTS

You should be aware that a patient seeking healthcare may be vulnerable and open to persuasive influences.You must not exploit such a situation. This would be a serious breach of trust. Examples of this might be:

• Subjecting a patient to an investigation or treatment that is unnecessary or not in their best interest.

http://www.osteopathy.org.uk/about_gosc/4387CodesOfPractice_A_W.pdf (http://www.osteopathy.org.uk/about_gosc/4387CodesOfPractice_A_W.pdf)

Not very impressive. All in all, it seems that ‘anything goes’ as long as there’s anecdotal evidence for it.

Mojo

5th March 2009, 12:02 AM

Osteopaths use hands-on manual techniques to treat patients with a wide variety of conditions arising from or affected by the musculo-skeletal system.

These conditions can include…tinnitus, sinusitis…irritable bowel syndrome, glue ear, colic... Would you please post the link to the General Osteopathic Council’s Code of Practice so that we can see what it says about osteopaths’ provision of care and evidence. Thanks.

The most relevant part of the Code of Practice (http://www.osteopathy.org.uk/about_gosc/4387CodesOfPractice_A_W.pdf) is probably:
PRACTICE INFORMATION

122.All advertising must be legal, decent, honest and truthful and must conform to the current guidance, such as the British Code of Advertising Practice.

The relevant section of the CAP code (http://www.asa.org.uk/asa/codes/cap_code/ShowCode.htm?clause_id=1770) is probably 50.1:
50.1 Medical and scientific claims made about beauty and health-related products should be backed by evidence, where appropriate consisting of trials conducted on people. Where relevant, the rules will also relate to claims for products for animals. Substantiation will be assessed by the ASA on the basis of the available scientific knowledge.

“Claims” of cures, as interpreted by the ASA, generally seems to include implied claims of cure such as “can be used to treat” etc.

OTOH, there are some claims made on the COsC website (http://www.osteopathy.org.uk/about_osteo/Babies_Children.pdf) which might have some bearing on whether the GOsC thinks the above claims are acceptable:
Many common problems suffered by babies and children can be treated effectively with osteopathy.

Problems often suffered by babies:

crying and irritability, especially when lying down.
feeding difficulties
sickness, colic and wind
sleep disturbances.

Problems often suffered by older childern:

musculo-skeletal problems
susceptibility to infections and a depleted immune system
ear infection, sometimes with a loss of hearing and 'glue ear'
sinus and dental problems, with a constantly blocked or runny nose
behavioural problems and learning difficulties, including poor concentration, fidgeting, difficulty in sitting and hyperactivity.
headache, other aches and pains.
asthma and vulnerability to chest infections.

Osteopathy can also help children suffering from cerebral palsy or Down's Syndrome.

davidrodway

5th March 2009, 12:41 AM

Any criticisms of the General Osteopathic Council, please address to them. The Code of Practice, Fitness to Practice, was subject to a much detailed criticism by osteopaths when it came out a few years ago (with no effect).

EBM - please look up on the south wales osteopathic society website - search for EBM and Research

Other points/ questions I will address when I have some time.

Silly question - what does WOO stand for?

David

davidrodway

5th March 2009, 12:57 AM

Waves at our sometime resident hit and run friend of the homeopath!

I've a bit of sinus trouble at the moment, what neck muscles should I be massaging to cure myself?

I do treat patients who have sinusitis. If you really had this , I doubt you would describe it as " a bit of sinus trouble" - so I suggest you carry on using whatever you have found helpful so far. Among the techniques I use are percussion ( gentle rapid tapping, not a blast of sound on the bongo drums) over the sinuses. I also show patients how to do this at home.

David

filippo lippi

5th March 2009, 05:59 AM

So, the neck rubbing wouldn't help my sinus pain. L+G we have a schism. Which is better? Neck rubbing or a tap on the nose? There's only one way to find out,

FIGHT!!!

Matt

5th March 2009, 07:11 AM

Silly question - what does WOO stand for?

David

Nothing, it's a prejorative term used by James Randi for various inexplicable claims and those who make them. Sometimes woo woo. Think of the sound that a ghost makes.

http://www.urbandictionary.com/define.php?term=woo%20woo

Mojo

5th March 2009, 08:24 AM

So, the neck rubbing wouldn't help my sinus pain. L+G we have a schism. Which is better? Neck rubbing or a tap on the nose? There's only one way to find out,

FIGHT!!!
And the winner is... (http://www.googlefight.com/index.php?lang=en_GB&word1=Neck+rubbing&word2=a+tap+on+the+nose)

Mojo

5th March 2009, 08:28 AM

Any criticisms of the General Osteopathic Council, please address to them. The Code of Practice, Fitness to Practice, was subject to a much detailed criticism by osteopaths when it came out a few years ago (with no effect).
The GOsC's code, and what it says about claims, are relevant to anyone legally calling themselves an osteopath in the UK.

Matt

5th March 2009, 09:18 AM

And the winner is... (http://www.googlefight.com/index.php?lang=en_GB&word1=Neck+rubbing&word2=a+tap+on+the+nose)
but (http://www.googlefight.com/index.php?lang=en_GB&word1=%22neck+rubbing%22&word2=%22a+tap+on+the+nose%22)

Blue Wode

5th March 2009, 09:26 AM

EBM - please look up on the south wales osteopathic society website - search for EBM and Research
That search produces one result:
http://www.osteopathywales.com/index.php?searchword=EBM+research&ordering=newest&searchphrase=all&option=com_search (http://www.osteopathywales.com/index.php?searchword=EBM+research&ordering=newest&searchphrase=all&option=com_search)

Clicking on the next page brings you to this:

Evidence is ranked according to the following classification in descending order of credibility:1. Strong evidence from at least one systematic review of multiple well-designed randomised controlled trials.2. Strong evidence from at least one properly designed randomised controlled trial of appropriate size.3. Evidence from well-designed trials such as non-randomised trials, cohort studies, timeseries or matched case-controlled studies.4. Evidence from well-designed non-experimental studies from more than one centre or research group.5 Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees

-snip-

Osteopaths accept the need for EBM. One problem for osteopaths is there has not been the research on which to base many decisions. Research has now become a priority for the profession, with the setting up of National Council for Osteopathic Research, the establishment of the International Conference on Osteopathic Research, and the dissemination of research results, especially via the International Journal of Osteopathic Medicine.

http://www.osteopathywales.com/index.php?option=com_content&view=article&id=140:evidence-based-medicine&catid=15:osteopathy-articles- (http://www.osteopathywales.com/index.php?option=com_content&view=article&id=140:evidence-based-medicine&catid=15:osteopathy-articles-)

So, at the moment, it looks like many osteopaths depend heavily on evidence level 4 or 5, does it not?

JJM

5th March 2009, 10:48 AM

{snip} OTOH, there are some claims made on the COsC website (http://www.osteopathy.org.uk/about_osteo/Babies_Children.pdf) which might have some bearing on whether the GOsC thinks the above claims are acceptable:
Many common problems suffered by babies and children can be treated effectively with osteopathy.

Problems often suffered by babies:

crying and irritability, especially when lying down.
feeding difficulties
sickness, colic and wind
sleep disturbances.

Problems often suffered by older childern:

musculo-skeletal problems
susceptibility to infections and a depleted immune system
ear infection, sometimes with a loss of hearing and 'glue ear'
sinus and dental problems, with a constantly blocked or runny nose
behavioural problems and learning difficulties, including poor concentration, fidgeting, difficulty in sitting and hyperactivity.
headache, other aches and pains.
asthma and vulnerability to chest infections.

Osteopathy can also help children suffering from cerebral palsy or Down's Syndrome.
{snip}
http://www.osteopathywales.com/index.php?searchword=EBM+research&ordering=newest&searchphrase=all&option=com_search (http://www.osteopathywales.com/index.php?searchword=EBM+research&ordering=newest&searchphrase=all&option=com_search)

Clicking on the next page brings you to this:
{snip} One problem for osteopaths is there has not been the research on which to base many decisions. {snip}
So, at the moment, it looks like many osteopaths depend heavily on evidence level 4 or 5, does it not?Perusing the fanciful list of conditions provided by Mojo, and the quote provided by Blue Wode, it is obvious that osteopaths in the UK are as quacky as chiropractors in the UK and USA.

davidrodway

5th March 2009, 11:04 PM

So, the neck rubbing wouldn't help my sinus pain. L+G we have a schism. Which is better? Neck rubbing or a tap on the nose? There's only one way to find out,

FIGHT!!!

L+G.Excuse my ignorance, cant place the abbreviation. Who suggested neck rubbing? And the maxiillary sinuses, for example, are not in the nose. Why are you asking me about your sinus pain? I assume you are having adequate professional care .

davidrodway

5th March 2009, 11:08 PM

Nothing, it's a prejorative term used by James Randi for various inexplicable claims and those who make them. Sometimes woo woo. Think of the sound that a ghost makes.

http://www.urbandictionary.com/define.php?term=woo%20woo
And I was trying to think of so many clever acronyms. So who decides what is woo and what isnt? Ghosts dont exist, so they cant make noises.

Dubious Dick

5th March 2009, 11:14 PM

And I was trying to think of so many clever acronyms. So who decides what is woo and what isnt? Ghosts dont exist, so they cant make noises.

Woo is non credible evidence based. Lack of credible evidence is evident, evidently.

Allow us skeptics a little light humour as regards using 'ghost' noises, please.

Some skeptics do not like the use of the expression but it can be helpful shorthand sometimes.

davidrodway

5th March 2009, 11:19 PM

The GOsC's code, and what it says about claims, are relevant to anyone legally calling themselves an osteopath in the UK.

But if you really want an official explanation of what is in the GOsC code and why, please ask them. It just got dumped on us and many osteopaths were not too pleased about it. I am not going to be an apologist for a document with which I had many misgivings.

Any specific points on which you want my personal opinion?

filippo lippi

5th March 2009, 11:25 PM

L+G.Excuse my ignorance, cant place the abbreviation. Who suggested neck rubbing? And the maxiillary sinuses, for example, are not in the nose. Why are you asking me about your sinus pain? I assume you are having adequate professional care .

NMT (who seems to have fled) defended neck massage (don't say "manipulation" it make him mad>:-)) as a cure for sinus pain.

davidrodway

6th March 2009, 02:28 AM

NMT (who seems to have fled) defended neck massage (don't say "manipulation" it make him mad>:-)) as a cure for sinus pain.

Haven't caught up yet with replies to posts that i assume are meant for me, so not able yet to go back and comment on others. Please see SWOS website for "manipulation".

davidrodway

6th March 2009, 02:40 AM

Woo is non credible evidence based. Lack of credible evidence is evident, evidently.

Allow us skeptics a little light humour as regards using 'ghost' noises, please.

Some skeptics do not like the use of the expression but it can be helpful shorthand sometimes.

Lack of credible evidence is not at all always evident.

There is a danger surely of someone sticking a woo or non woo label on a practice and then it either gets backed or attacked by everyone else. Sloppy thinking is such an easy option, and having someone you usually agree with categorize something for you so you know whether to support or attack it is hardly good skepticism.

Lets se the list of woo and non woo and why, if there is one

davidrodway

6th March 2009, 03:02 AM

Perusing the fanciful list of conditions provided by Mojo, and the quote provided by Blue Wode, it is obvious that osteopaths in the UK are as quacky as chiropractors in the UK and USA.

Dont quite follow your reasoning there. Are you making some connection between the two quotes, or just listing them?. Hope the following deals with your point. Haven't had a chance to reply to either of those you quote yet, but -

The first quote is about osteopaths who use cranial osteopathy or treat children, which is not every osteopath or even the majority, as far as i know.

The level of evidence may be 4 or 5 , but i understand those levels, although not the best, are acceptable. But i was going to challenge on what basis he/she had decided the evidence was at this level.

Suggest you visit the Research page on the SWOS website. You should be able, shoukd you wish, to track down the references and decide for yourself which level of evidence they provide.

Regarding chiropractors - i think you should take specific claims, either by chiropractors or osteopaths - and question the specific point, Just asking "is this profession quackery" is a bit like asking "is architecture quackery", rather than "is the building standing up" - although of course there are areas such as astrology or economics where its clear the whole sorry lot is rubbish.

davidrodway

6th March 2009, 03:13 AM

That search produces one result:
http://www.osteopathywales.com/index.php?searchword=EBM+research&ordering=newest&searchphrase=all&option=com_search (http://www.osteopathywales.com/index.php?searchword=EBM+research&ordering=newest&searchphrase=all&option=com_search)

Clicking on the next page brings you to this:

So, at the moment, it looks like many osteopaths depend heavily on evidence level 4 or 5, does it not?

Not sure why you say that. Have you looked at the Research page? You may be right, though, but level 4 or 5 , although not the best, is regarded acceptable, i beleive.

Quite happy - well unhappy really - to admit that the amount of research is little, although accelerating. However, as a profession we are supportive of research and keen to learn the from it and incorporate the fruits of research into practice.

davidrodway

6th March 2009, 03:37 AM

The immediate problem is that there is no known mechanism by which the ear is directly linked to musculo-skeletal system and so the claim that treating one can effect a therapy in the other immediately rings alarm bellsFor a direct association to be true, it would have to overturn a lot of scientific and medical evidence, which would make it an extraordinary discovery.=

I assume from what you have said that you are not a believer in subluxations and similar?[/quote]

Well I can think of two links ( do i get the Nobel prize?) -
1 Pintos ligament
2 the anterior cervical muscles (supra and infra hyoid)
Jut your head forward and try closing your jaw - how easy is that? Most of you will feel the jaw being pulled back and dificulty closing the jaw.Forward head posture is quite common and can result in altered occlusion and compression of the tmj and its intra articular disc.

Subluxations? No

dizzyblonde

6th March 2009, 07:29 AM

Umm there is a sensory neurological link between the ear and the cranial nerves. This from wikipedia....

Cervical spinal nerves (C1-C4)
Further information: Cervical plexus (http://www.skeptics.org.uk/wiki/Cervical_plexus)
The first 4 cervical spinal nerves, C1 through C4, split and recombine to produce a variety of nerves that subserve the neck and back of head.
Spinal nerve C1 is called the suboccipital nerve (http://www.skeptics.org.uk/wiki/Suboccipital_nerve) which provides motor innervation to muscles at the base of the skull (http://www.skeptics.org.uk/wiki/Skull). C2 and C3 form many of the nerves of the neck, providing both sensory and motor control. These include the greater occipital nerve (http://www.skeptics.org.uk/wiki/Greater_occipital_nerve) which provides sensation to the back of the head (http://www.skeptics.org.uk/wiki/Head_(anatomy)), the lesser occipital nerve (http://www.skeptics.org.uk/wiki/Lesser_occipital_nerve) which provides sensation to the area behind the ears (http://www.skeptics.org.uk/wiki/Ear), the greater auricular nerve (http://www.skeptics.org.uk/wiki/Greater_auricular_nerve) and the lesser auricular nerve (http://www.skeptics.org.uk/wiki/Lesser_auricular_nerve). See occipital neuralgia (http://www.skeptics.org.uk/wiki/Occipital_neuralgia). The phrenic nerve (http://www.skeptics.org.uk/wiki/Phrenic_nerve) arises from nerve roots C3, C4 and C5. It innervates the diaphragm (http://www.skeptics.org.uk/wiki/Diaphragm_(anatomy)), enabling breathing. If the spinal cord is transected above C3, then spontaneous breathing is not possible. See myelopathy (http://www.skeptics.org.uk/wiki/Myelopathy)

davidrodway

6th March 2009, 10:24 AM

JJM

6th March 2009, 10:40 AM

To repeat from Blue Wode's citation
4. Evidence from well-designed non-experimental studies from more than one centre or research group.5 Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees

-snip- One problem for osteopaths is there has not been the research on which to base many decisions.
Dont quite follow your reasoning there. Are you making some connection between the two quotes, or just listing them?. Hope the following deals with your point. Haven't had a chance to reply to either of those you quote yet, but -

The first quote is about osteopaths who use cranial osteopathy or treat children, which is not every osteopath or even the majority, as far as i know. One must go with the lowest common denominator for a group. Who protects people from that group, and how is that done?

The level of evidence may be 4 or 5 , but i understand those levels, although not the best, are acceptable. But i was going to challenge on what basis he/she had decided the evidence was at this level.We call evidence level '5' anecdote; it is not acceptable recommending treatment. It can be a basis for starting a rigorous pilot study which may then be the basis for a full-scale program. Evidence level '4' is a little better; but it depends on the number of subjects and the condition treated. It is not a substitute for an RCT. What is the level of evidence for your treatment of sinusitis?

{snip} Just asking "is this profession quackery" is a bit like asking "is architecture quackery", rather than "is the building standing up" - {snip}I don't follow your logic here. We certainly can identify quackery and when it pervades a group they are quacks. Quackery is the pretense to medical knowledge in the absence of it.

ETA: I forgot to comment on the final part of the quote "there has not been the research on which to base many decisions." How much clearer can it be? Osteopaths are working as if they know what they are doing; but they don't.

Blue Wode

6th March 2009, 10:49 AM

Regarding chiropractors - i think you should take specific claims, either by chiropractors or osteopaths - and question the specific point
The evidence for chiropractic was recently thoroughly evaluated by two impartial scientists, Simon Singh and Edzard Ernst, and the following is what they propose on page p.285 of their book, Trick or Treatment? Alternative Medicine on Trial, that all chiropractors be compelled by law to disclose to their patients:

“WARNING: This treatment carries the risk of stroke or death if spinal manipulation is applied to the neck. Elsewhere on the spine, chiropractic therapy is relatively safe. It has shown some evidence of benefit in the treatment of back pain, but conventional treatments are usually equally effective and much cheaper. In the treatment of all other conditions, chiropractic therapy is ineffective except that it might act as a placebo.”
It begs the question, why would anyone waste their money or risk their life going to a chiropractor?

As for osteopathy, we already know what they concluded about that in their book, but here’s a reminder:

The evidence that the osteopathic approach is effective for treating back pain is reasonably sound. If, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercise, which is backed by similar evidence and which can be done in groups and therefore is more cost-effective. There is no evidence to support osteopathy for the treatment of non-musculoskeletal conditions.

(Page 321)

They also said the following about osteopathy in a newspaper article last year:

In general they treat mainly musculoskeletal problems, but many also claim to treat other conditions such as asthma, ear infection and colic.
http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=17 74&ICO=HEALTH&ICL=TOPART (http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=1774&ICO=HEALTH&ICL=TOPART)

It indicates that they don’t think that asthma, ear infections, colic, etc., are musculoskeletal in origin.

Regarding my comments,

So, at the moment, it looks like many osteopaths depend heavily on evidence level 4 or 5, does it not?
Not sure why you say that.

I'm following what the science tells us, as per Singh and Ernst. Is there any other conclusion that can be drawn?

dizzyblonde

7th March 2009, 08:05 AM

Just a technical point - these are cervical spinal nerves not cranial nerves (On Old Olympus Towering Top etc), but you are right about the nerve supply. But dont forget that most of the sensory innervation to the face is by the trigeminal nerve (which is a cranial nerve of course)

Oh yes! I meant cervical not cranial. Thanks David.

davidrodway

7th March 2009, 04:45 PM

JJM and Bluewode

Sorry for the delay in replying. There are also some previous posts that I have not yet had time to answer fully, but rather than delay I will try and address the more recent points.

Lowest common denominator –
I take your point. All osteopaths have to qualify from one of the colleges recognized by the GOsC to call themselves an osteopath, so all should have the diagnostic skills and knowledge to know when to refer rather than treat the patient. “Cranial” is usually done at PG level. Thus all osteopaths are subject to the GOsC whether they use no cranial (most osteopaths), some, or only cranial (a small number).

Cranial osteopaths and cranio-sacral therapists are not the same. You cannot call yourself craial osteopath, or any sort of osteopath, unless you are on the GOSC register. However cranio-sacral therapy is, unlike osteopathy (Osteopaths Act 1993), unregulated and anyone can call themselves one. Cranio-sacral Therapy was started in the States by an osteopath called Upledger who “trained” anyone regardless of whether or not they had any training in osteopathy or medicine. That is still going on and has now spread to Britain. There is nothing the GOsC can do about it. So it is quite important to distinguish between the two.

Evidence lrevel 5 and anecdote.
Who is this “we” exactly? I am familiar with “anecdote”. With respect I think you will find anecdote and level 5 are not the same. Anecdote is just a practitioner saying ” I saw a patient , did this and that happened” .(“n=1”).Level 5 of course isn’t as good as RCT

That quote about research on the SWOSwebsite was one of my contributions and I apologise, because it obviously isn’t really clear at all. It refers to research, and research is not the same as evidence, There can be evidence to support an investigation or treatment that derives from sources other than research (although research based evidence is better) – including a consensus of experienced opinion, for example.

Some of the research relevant to osteopathy (as opposed to just evidence) is listed on the website. on its own page. Probably the biggest research project was the BEAM trial (see website again). RCTs are, as you say, the gold standard. We are still trying to work out how to do double blind trial of osteopathy (The osteopath must not know whether he is giving the right treatment or not – any suggestions as to how we do that?). Single blind trials may be possible (patient not knowing) but even those would be difficult.

The point is that osteopaths are not research averse.

One route is through clinical audit. The Osteopathic research council is currently developing a standardised audit tool that can be used by osteopaths throughout Britain to collect data.

Identify quackery –
To assess whether osteopathy for example is quackery you first have to know a little at least about how osteopaths are educated and what they do. Training is similar to medicine, except without the pharmacology, and with more concentration on subjects such as biomechanics and technique. Osteopaths use the same anatomy and physiology books – we do not have an alternative anatomy like say the acupunturists with their meridians.

Perhaps we could have a quiz to evaluate each others medical knowledge?

I would guess 95% of osteopaths treat musculo-skeletal complaints 95% of the time.True we do sometimes think “outside the box” and have a slant on things that would be different from say a GPs (see , eg, the case studies on the website).

Just another comment on the research side. Say I have a patient come in with an acute neck pain. I do my case history and examination, exclude serious pathology and decide from what I have been taught that she has a Z joint (facet joint) problem , the sort which through my and others past experience improves quickly (ie by the end of one treatment ) to soft tissue stretching and a judicious LAHVT. Am I suppose to say “Well I think I can help you but the rearch isn’t watertight so please go away. “ We have to do the research , but meanwhile we have to use what knowledge we have. I use soft tissue stretching before the LAHVT because I think it relaxes the muscles and I can therefore use much less force when doing the LAHVT. It makes sense to me, but there isn’t the research to back that up. Do I not do soft tissue stretching until the research on that is done?There are many decisions that a practitioner (including GPs and surgeons) makes throughout the day that have to be based on the best available information, even if that best is not as good as it might be a few years down the line when further research is done.

Ernst, Singh and Trick or Treatment -

First let me say that I think the BCA suing Singh is appalling and ridiculous. It’s a threat to free speech. And scientific/clinical disputes are not settled by suing people.

I am familiar with the book and some of its contents

I am not sure about what they say about “physiotherapeutic exercise”.The physios in the NHS hospitals here do not , I think, give exercises in groups, although they do give advise individual patients exercise - usually the same one regardless of what is wrong with them – a sort of modified push up to “strengthen the back muscles” (if the back muscles are weak, why don’t they fall over?)

I am not against exercise properly done – I often advise patients for example to go to Pilates (belly dancing is also good for low backs)

A lot of patients come to see us after they have tried physio without benefit.

I cant believe a “skeptic” gets their medical information from the Daily Mail!

Back to research – esp on non-musculoskletal research. Ernst seems to have overlooked some. I found this when I submiited some cmments on line to Pulse. I am looking back to find the references that I found that he seemed to have missed (ignored?), hence my delay in replying. So more on that later. So don’t rely to heavily on Prof Ernst.

Pebble

7th March 2009, 05:20 PM

davidrodway

7th March 2009, 07:07 PM

davidrodway

7th March 2009, 07:15 PM

Agreed that double blind trials are difficult, given that the mechanism of putative benefit is dubious and the operator can hardly be blinded. However, for most conditions treated there are alternatives, so it is certainly possible to do randomised trials.

Given this it is certainly reasonable to not treat conditions for which there is no evidence that osteopathy is at least as effective as proven conventional therapies.

Admitting that there are intractable conditions for which there is no known effective therapy is another important step, it is not sufficient to say that conventional therapy has failed so one must try something - even where there is no evidence. When approaching such patients enrollment into a trial is the only effective way to go, trying unregulated, un-audited, non-registry based messing may make the practicioner feel they are 'doing something' for the patient, but in reality they are simply fooling themselves and the patient.

The sort of RCTs you describe are certainly possible and some have been done Eg BEAM trial. Dont forget also that there are other elements in the effectiveness equation - such as cost and risk of advesrse events (eg death by bleeding gut with NSAIds)

Admission of intractable conditions, yes, but not giving up on patients when there are treatments that fall outside the scope of the NHS,

Osteopathy is regulated, as I said we are introducing audit, dont understand your use of the term "non-registry". I do not do messing - I make a diagnosis based on history and examination, and further investigation such as MRI if needed, and draw up a ttt paln based on that. And if I think I cannot help - eg metastases, discitis, Parkinsons, aortic aneurysm, etc etc I refer on. Also if no real imporovement in 4 ttts, further investigation or referrral.

davidrodway

7th March 2009, 07:33 PM

The parents are heavily into this woo. Unfortanately their osteopath of choice diagnosed a serious condition in my father's leg where the GP had repeatedly failed. Obviously, the osteopath could do nothing about the condition and it was left up to proper doctors and surgeons to sort out, but because the quack made the correct diagnosis he can do know wrong in the parents' eyes.[/quote]

How come the "quack" (osteopath) is the one that made the correct diagnosis ("Unfortunately" he helped your parents!).If he had not, or had treated and not refered on, the the tag might be justified, but as he did the right thing , surely that is an unfair label. Why dont you phone him and thank him for helping to preserve your parents health (or were you looking forward to some money in the will?) Perhaps better a skilled and clever "quack" than a "proper doctor" who cannot make a correct diagnosis. Or is that too skeptical?

Reminds me of a patient I saw with pulsating headache. took his bp - 170/120! Sent him straight to GP with nice letter.GP said "If youve got a headache your bp s bound to go up"! Didnt even tead the letter or take his bp. Next day pt felt v ill, went to surgery, sensible nurse took bp, so high she wouldnt let him leave. Doctor (no apology from him) finally decides to do something about the bp.

And if your medical world is divided into quacks and proper doctors, what then of those osteopaths who have gome on to train as doctors or thedoctors who have trained in osteppathy at the LCOM? Or is that a little too cofusing for you

Can you not see the difference between skepticism and blind deference to orthodoxy?

Or see below
//"Very unhelpful, arrogant," it said of a doctor. "Did not listen and cut me off, seemed much too happy to have power (and abuse it!) over suffering people."//

Many of my patients over my working life have expressed such sentiments to me, about their GP's attitude and behaviour, which has not been wholly limited to GPs; physiotherapists and hospital consultants have been just as damned bad!
I will provide you with a good example which happened to me in the first year of my self employed practice life, post grad 83'.

A late middle age lady consulted me complaining of long standing low back pain. Prior to her consultation, she asked for her GPs veiws and opinions on her attending my practice, as she wasn't getting anywhere with physio or his own 'medicine'. In no uncertain terms, he requested she stand up and turn around and upon her submissive acquiescence, he squeezed her buttock so hard it bruised and said ''there you go madam...and I won't even charge £10 for that''.
I don't have to tell you how that left both the patient and myself feeling. But, as he was an very well respected OBE decorated GP in my home town, what could we do?
Anyway, with a living to make and a patient in pain, I judiciously began to missapply the 'osteopathy' I was mistaught at the BSO to her unsuspecting body and against all the odds, she gradually got better; and the seeds were set for the mythopoeic status of 'The Osteopath to Follow' which I still enjoy today (as is the experience of us all).
The story doesn't quite end there. After sometime, that same GP began sending me patients with the advice ''you couldn't do better than to see that lad with your back...I delivered him into this world you know''!! he had been my families GP for 3 generations! What do you think to that folks?
What can we learn from all of this in light of JJs post. For me I refer to one of my best loved philosophers Michel de Montaigne who said;

...'Upon the highest throne in the world, we are seated, still, upon our arses'...

Those in power often need a kick up theirs!

Blue Wode

7th March 2009, 08:08 PM

Thank you for your response, David.

Cranial osteopaths and cranio-sacral therapists are not the same.
That might be so, but at the end of the day both types of therapists are offering a treatment for which Simon Singh and Edzard Ernst say there is no convincing evidence that it is effective for any condition. Therefore, it has to follow that any osteopath who offers cranial osteopathy is contravening Section 8 of the GOsC’s Code of practice:

UNDUE INFLUENCE ON PATIENTS

You should be aware that a patient seeking healthcare may be vulnerable and open to persuasive influences.You must not exploit such a situation. This would be a serious breach of trust. Examples of this might be:

• Subjecting a patient to an investigation or treatment that is unnecessary or not in their best interest.

http://www.osteopathy.org.uk/about_gosc/4387CodesOfPractice_A_W.pdf (http://www.osteopathy.org.uk/about_gosc/4387CodesOfPractice_A_W.pdf)

David Rodway wrote:

Some of the research relevant to osteopathy (as opposed to just evidence) is listed on the website. on its own page. Probably the biggest research project was the BEAM trial (see website again).
The BEAM trial estimated the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to "best care" in general practice for patients consulting with back pain. It is interesting to note what Edzard Ernst had to say about it:

Three brief comments on the excellent BEAM Trial (1). My reading of the results is that the data are compatible with a non-specific effect caused by touch: exercise has a significantly positive effect on back pain which can be enhanced by touch. If this “devil’s advocate” view is correct, the effects have little to do with spinal manipulation per se.

It would be relevant to know which of the three professional groups (chiropractors, osteopaths, physiotherapists) generated the largest effect size. This might significantly influence the referral pattern. A post-hoc analysis might answer this question.

It is regrettable that the study only monitored serious adverse effects. There is compelling data to demonstrate that minor adverse effects occur in about 50% of patients after spinal manipulation (2). If that is the case, such adverse events might also influence GP’s referrals.

1. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ, doi:10.1136/bmj.38282.669225.AE. BMJ 2004;19 November:1-8.
2. Stevinson C, Ernst E. Risks associated with spinal manipulation. Am J Med 2002;112:566-70.

http://www.bmj.com/cgi/eletters/bmj.38282.669225.AEv1#88126 (http://www.bmj.com/cgi/eletters/bmj.38282.669225.AEv1#88126)

David Rodway wrote:

Identify quackery –
To assess whether osteopathy for example is quackery you first have to know a little at least about how osteopaths are educated and what they do. Training is similar to medicine, except without the pharmacology, and with more concentration on subjects such as biomechanics and technique. Osteopaths use the same anatomy and physiology books – we do not have an alternative anatomy like say the acupuncturists with their meridians.
It’s interesting what Rose Shapiro has to say about osteopaths in the ‘Bad Backs’ chapter of her book, Suckers: How Alternative Medicine Makes Fools Of Us All:

“The UK’s 5,000 or so osteopaths require no scientific medical training and so are more firmly established in the ‘alternative’ camp. Very few are MDs and many combine osteopathy with dubious practices such as naturopathy and cranial osteopathy.
And Singh and Ernst say the following on page 321 of their book, Trick or Treatment? Alternative Medicine on Trial:

In the UK, osteopaths are regulated by statute but considered to be complementary/alternative practitioners.
David Rodway wrote:

Just another comment on the research side. Say I have a patient come in with an acute neck pain. I do my case history and examination, exclude serious pathology and decide from what I have been taught that she has a Z joint (facet joint) problem , the sort which through my and others past experience improves quickly (ie by the end of one treatment) to soft tissue stretching and a judicious LAHVT. Am I suppose to say “Well I think I can help you but the research isn’t watertight so please go away.” We have to do the research , but meanwhile we have to use what knowledge we have. I use soft tissue stretching before the LAHVT because I think it relaxes the muscles and I can therefore use much less force when doing the LAHVT. It makes sense to me, but there isn’t the research to back that up. Do I not do soft tissue stretching until the research on that is done?
Those are quite worrying comments when you consider what Dr Mark Crislip had to say recently on the subject of chiropractic neck manipulation and stroke:

If you want to increase the chance of injury from relatively minor trauma, have the person relax. If the muscles are relaxed because the person is not expecting the trauma, the chance of injury goes up. It is why whiplash can occur after minor injuries (4). Chiropractors often have their patients relax just before the coup de grace, I mean manipulation, helping to maximize the chance of injury despite having less force applied to the neck than a noose and gravity.
http://www.sciencebasedmedicine.org/?p=170 (http://www.sciencebasedmedicine.org/?p=170)

And Dr Harriet Hall made similar comments a few days ago:

The unspoken implication is that the stroke would have happened anyway even if the patient hadn’t seen a chiropractor, and that chiropractic manipulation is no more traumatic than watching airplanes. That’s clearly wrong, because more force is exerted when a chiropractor rapidly twists a relaxed neck than when someone extends his own neck to look at the sky. When someone turns his neck himself, his muscles actively stabilize the neck and protect it from injury.
http://www.sciencebasedmedicine.org/?p=362 (http://www.sciencebasedmedicine.org/?p=362)

David Rodway wrote:

There are many decisions that a practitioner (including GPs and surgeons) makes throughout the day that have to be based on the best available information, even if that best is not as good as it might be a few years down the line when further research is done.
But the best available information on treating neck pain is to use exercise:

Spinal manipulation for neck pain is a treatment with unknown benefits and unknown harm. Because of this and the fact that serious risks are on record, a responsible risk–benefit assessment cannot ignore the risks and cannot come out in favour of spinal manipulation.

Remember the supreme law in medicine: first do no harm. Other therapies for neck pain exist, e.g. exercise, which are supported by at least as good evidence for benefit and which are at the same time free of significant risks.

The inescapable recommendation based on the best evidence available today is to use exercise rather than spinal manipulation as a treatment for neck pain.

http://www.medicinescomplete.com/journals/fact/current/fact0902a06d01.htm (http://www.medicinescomplete.com/journals/fact/current/fact0902a06d01.htm)

David Rodway wrote:

I cant believe a “skeptic” gets their medical information from the Daily Mail!
That fact that it was the Daily Mail is irrelevant since it was Simon Singh and Edzard Ernst who wrote the piece. Indeed, on checking their information source, I discovered that the osteopathy section was lifted, unedited, from page 321 of their book, Trick or Treatment? Alternative Medicine on Trial.

David Rodway wrote:

…don’t rely too heavily on Prof Ernst.
Why not? Isn’t he likely to be more impartial than researchers who are osteopaths? What reason would Ernst have to mislead health-care professionals on scientific research?

davidrodway

7th March 2009, 10:18 PM

Dear Bluewode

Glad to see that you have visited the SWOS and GOsC websites

Nice point about “cranial” and the GOsC Code. I think that the response would be (But why not ask the GOsC directly?) that, if challenged, the “cranial” osteopath would say that they believe (and they really will) that what they are doing is in the patients best interests. They will no doubt point to a long long list of very satisfied patients. Anecdotal of course, but, were a complaint made against them on this point, they would be able to call on many patients who would be more than happy to testify that they or their child had been helped enormously where others - perhaps even non –cranial osteopaths - had failed.
And they would trot out of course “Lack of evidence is not evidence of lack” or however it goes.
Nonetheless, a challenge to “cranial” along these lines would be very interesting. It could happen.
BEAM (only one of course of the list of research on the website). Ernst says it is his reading of it. So I assume there are others that vary. Interestingly he says (I think) that he thinks that touch enhances the benefits of exercise . Or is it exercise enhances the benefits of touch. Are we talking, all touch, any touch, touch by osteopaths, touch by physios? Is touch by osteopaths better than touch by physios.? A lot of the benefit of osteopathy is because of touch - that is the point. Doesn’t mean that just getting your husband/wife to toch you is going to be as beneficial for your health/pain as an osteopaths touch (although it might be)
Certainly agree with Ernst it’s a pity that the osteros/chiro/physio interventions were not split. Why were they not?. If it can now be done at this late stage I would be v interested to see the results
Shapiro – not familiar with this name I admit. But on osteopathic education her facts as quoted here are totally totally wrong. Even when I trained 30 years ago we used the standard anat and physiological and clinical methods texts (Greys, Guyton, Hutchinson, Apleys etc) and were taught by doctors and surgeons, saw dissections etc. Didn’t do stats then but they do now. All my training was osteopathic under grad and PG If using an opthalmoscope for example or using the hypotheco-deductive method of diagnosis (as used by the medics) isn’t scientific, I don’t know what is. On this point I am adamant – I was there and I know what was and is taught and how. Will be contacting her to see where her information come from

What next?
Neck treatment. Not sure of the source of your neck exercise is best quote. What neck exercises anyway?
Osteopaths have a range of manual techniques of which LAHVT (low amplitude high velocity thrust ) is just one. It works well, I find , in the acute neck as in slept awkwardly a few days ago and cannot move neck to one side without pain since. The patient cannot “Exercise” the neck even if they wanted to - it is usually too painful for active movement in at least 2 directions. TTT usually gives relief and increased mobility by the end of the treatment.
Whiplash is so devastating not just because the subject is (sometimes) relaxed. There are several other factors.
If the patients muscles were not relaxed, that would be a contra-indication to LAHVT ( the practitioner would eitjher have to use too much force or just “bounce off”). Bear in mind also that chiropractic and osteopathic LAHVTs are done differently – chiropractors often use plinths with flaps that give way under the patients neck sc they apply a sideways karate chop style thrust to the neck.

We are still told, however, before using a n LAHVT to the patients upper cervical spine to advise them of possible risks (again see website) and ask their explicit permission to proceed. Never been a recorded case of stroke through an osteopaths LAHVT as far as I know, but we still have to ask them.

I should also add that before an LAHVT we will test eg auscultate for carotid bruit. Also the history may point against LAHVT – eg drop attacks, clotting disorders – in which case no LAHVT is done
Ernst – not decrying him completely, just saying he is not the sole authority. For example (without looking it up again ) I think there was something in that advice he gave in the Daily Mail about making sure that the osteopath would not use vigorous treatment if the patient told them they had cancer, bone infection, clotting disorders and some others. This implies he does not realise that an osteopath will know not to use certain techniques if these conditions are present.The osteopath actually will be making enquiry during the history about these conditions – and not just asking the patient about conditions the patient knows they have, but also asking about symptoms that may indicate those conditions – eg “ are you on Warfarin, do you bruise easily”!. See for example on the SWOS website under “Spinal Cancer”. Not only would the osteopath not be using certain techniques in those conditions, they probably would not be treating them at all! Eg – osteomyelitis – the osteopath will refer on . Point is, why doesn’t Ernst know that is what is what we do? Should he not visit a few osteopathic colleges?. He can come to my practice if he likes and watch me work.

Ernst impartial – trouble is he doesn’t do research of his own as far as I know. And he has overlooked some that has been done (references to folllow as I said before)

Who should do research –If osteopaths do it the results are “biased”, if we do not do it we are criticised for not doing our own research If we use other peoples results we are “piggy backing”. Cant win .l I think osteopaths and non-osteopaths should do the research and then the studies stand on their own merits.
Sorry about the numerous typos. Too knackered now to correct them

Pebble

7th March 2009, 10:53 PM

The sort of RCTs you describe are certainly possible and some have been done Eg BEAM trial. Dont forget also that there are other elements in the effectiveness equation - such as cost and risk of advesrse events (eg death by bleeding gut with NSAIds)

I know, but to shed the label of being woo requires a little more: a body of consistent evidence that demonstrates consistent efficacy in a given condition, ideally backed by a plausible mechanism of action. Apart from low back pain, where there are more cost effective alternatives, osteopathy struggles here.

of intractable conditions, yes, but not giving up on patients when there are treatments that fall outside the scope of the NHS,

Doing proper trials is not giving up, it is an admission that you do not know what to do, but there are others who are trying to find ways forward, and having the humility to search such people out and refer on.

Osteopathy is regulated, as I said we are introducing audit, dont understand your use of the term "non-registry". I do not do messing - I make a diagnosis based on history and examination, and further investigation such as MRI if needed, and draw up a ttt paln based on that. And if I think I cannot help - eg metastases, discitis, Parkinsons, aortic aneurysm, etc etc I refer on. Also if no real imporovement in 4 ttts, further investigation or referrral.

In many situations there is insufficient information on the natural history of a condition to set up proper trials. here one sets up registries following the 'natural history' of the condition. This then allows planning for the appropriate size of trial for a given magnitude of expected treatment effect.

As for your subsequent post, cannot quite understand where you are quoting from, but in essence this is a series of anecdotes, well done. The tabloids may wish to recruit you. The argument appears to be there are crap GPs so osteopaths must have a role!

davidrodway

8th March 2009, 12:21 AM

I know, but to shed the label of being woo requires a little more: a body of consistent evidence that demonstrates consistent efficacy in a given condition, ideally backed by a plausible mechanism of action. Apart from low back pain, where there are more cost effective alternatives, osteopathy struggles here.

Doing proper trials is not giving up, it is an admission that you do not know what to do, but there are others who are trying to find ways forward, and having the humility to search such people out and refer on.

In many situations there is insufficient information on the natural history of a condition to set up proper trials. here one sets up registries following the 'natural history' of the condition. This then allows planning for the appropriate size of trial for a given magnitude of expected treatment effect.

As for your subsequent post, cannot quite understand where you are quoting from, but in essence this is a series of anecdotes, well done. The tabloids may wish to recruit you. The argument appears to be there are crap GPs so osteopaths must have a role!

I thougt it easier , less tedious for the reader to not use the quote facility,(but appatently not - shows what thinking for yourself does). If you care to look back on bluewodes and the other guys postings you will see whsat i am refrering to. If not, just say,

So :
Shed the idea of woo . When and where and by who and why was that pinned on me and my profesision in the first place?

Cost effectiveness for back pain - i think not (unless you thnk the NHS is "Free"). Of course, add in the cost of the patient being off work.

Plausible mechanisms - shall we talk neurology here?: I have put my qualifications and background on the line - what are yours? Do you want a debate about neuromuscular spindles or Golgi tendon organs , or any other biological event or apparatus you care to name?

Your second and third paragraphs I do not see I have any disagreement with , nor does it conflict, as far as i can see, with what i have said in past posts

About the crap GPs - one point is that just because someone may be "orthodox" does not mean they are any good.Another is that osteopaths use many of the diagnostic procedures used by orthodox medicine . but still those methods get labelled woo just because they are done by osteopaths.

If you want to take my own recorde of the patient with the hi bp - the point i was making , among others, i as a supposedly WOO practitioner did the ethical and scientific thing, wheras the GP apparently did not.

So why judge professions and not individuals? There are lots of WOO, or jyut rubbisg, GPs out there. How many non WOO osteopaths compared to WOOO or poor GPs do you need before you start to question your allegiance to a particular profession?

Anyway, sceptic has a c in it not a bloody k

Pebble

8th March 2009, 07:23 AM

davidrodway

8th March 2009, 11:26 AM

Woo:

http://www.osteopathy.ie/history.htm

He believed that the human body was self-healing (Hippocrates thought this somewhat earlier), and that uninterrupted nerve and blood supply to all the tissues of the body was indispensable to their normal function (even Galen thought this though for the wrong reasons). If any structural problem, e.g. muscle spasm, curvature of the spine, etc. interfered with the nerve and blood flow (blood flow and minor spinal abnormalities?), the self healing power was interfered with, and disease would result. With this in mind, he worked out a system of manipulation/adjustment intended to re-align any structural deviations and abnormalities.

So individuals with kyphoscoliosis must have very poor healing abilities! Clearly recovery from colds and sinus disorders must be very delayed in such individuals -

So here's the problem - assuming that there is one explanation for the variety of problems that the body suffers from and hence one approach to treatment.

Cost effectiveness: thinking is not evidence!

Plausible mechanism:

No one is going to argue that the brain and nervous system is irrelevant in disease and especially back pain - so in this respect he was a little ahead of his time - but accepting that he had a point and incorporating that into the general body of advancing knowledge as and when evidence supports, is one thing. Assuming that an insight from a 10 years old body is the central tenant by which all diagnostics and treatment should follow is another.

Appeal to authority:

I am unclear why qualifications should help in debate but if you want a list am happy: MB BCh BAO MRCPI MD FRCP.

Dear Pebble (Alan?)

Although AT Still was the founder of osteopathy around 1870 no one now practices the way he did. His was a reaction to the medicine of the time - heroic amounts of opium and alcohol , about the only drugs available at the time. No x-rays, germ theory in its infancy. Even by 1900 removing an appendix was considerd a dangerous operation. I beleive it wasnt untill the 1930s the the presence of intervertebral disc prolapses were recognized.

Still used to treat almost everything - he thought that osteopathy midwifery and surgery were all you needed. But we are talking 140 years ago, and using what was done and said then is like judging modern surgery on the practices of the barber-surgeons. He came out with all sorts of sayings that either do not make sense or are obvious (The Rule of the Artery is supreme, or as I prefer, The Lure of The Treacle Tart is Supreme). What we can acknowledge is that he laid the foundations for a system of manipulation (which the chiropractors tried to copy some years later). For years osteopaths , in UK at least , were , as far as I know the only ones doing any sort of serious, educated hands on manipulation.

In more recent years physios have started doing some, following the teachings of Maitland, who, I understand, got his technqiues from watching osteopaths work (I think its called plagiarism).

Among doctors too manipulation was popularised by Dr James Cyriax who used very forceful manipluations to "Replace discal fragments". They are still there in the form of BIMM (Used to be called BAMM)

Osteopathy in Britain underwent a reform in the mid 1950s when a lot of the treatment of non-musculo-skeletal conditions was dumped and osteopathic assessment of the patient shifted from a description of positional lesions of spinal segments to one based on mobility and tissue changes.

It continues to change. In 1993 we had the Osteopaths Act which set up the GOsC. They in turn have set up NCOR, the National Council for Osteopathic Reseach. Undergrad studies have always used standard anatomical and medical texts and now the course include stats and research methodolgy. There is an annual international conference on research

AT Still probably would not like the osteopathy of today. We do not think that the spine is the source of all disease. Where we might disagree with some of the medical profession is that, in some patients, the musculo-skeletal system can have an influence on other body systems (the severe kypho-scoliosis you mentioned for example may have reduced rib expansion on breathing - is that WOO?)

If you want some modern osteopathic views please visit the site of the South Wales Osteopathic Society. I'm not saying that you wont find points on it to disgree with but it should give you a more accurate flavour of where osteopaths are today.

Any comment on my previous posts about the patient with the high blood pressure ?

Mojo

8th March 2009, 11:32 AM

No one is going to argue that the brain and nervous system is irrelevant in disease and especially back pain - so in this respect he was a little ahead of his time - but accepting that he had a point and incorporating that into the general body of advancing knowledge as and when evidence supports, is one thing. Assuming that an insight from a 10 years old body is the central tenant by which all diagnostics and treatment should follow is another.

The jump from a specific condition or a single case to a general principle, and the idea that a single basic treatment can cure any condition, is fairly characteristic of "woo", for example:

Cinchona bark treats malaria, and Hahnemann experienced fever-like symptoms after taking Cinchona bark, therefore any disease can be treated by something that produces its symptoms
Spinal manipulation appeared to restore a man's hearing, therefore any disease can be treated by spinal manipulations
Foot massages feel nice, so any condition can be treated by massaging the soles of the feet.

Similarly, the idea that all diseases have a single basic cause:

Obstruction of nerve signals (e.g. chiropractic)
Psora or Miasms (homoeopathy)
obstruction of the flow of Qi along meridians (TCM)
Imbalance of "humours" (Ayurveda, 18th century "allopathy")
A slightly less sweeping example: all cancers are caused by liver flukes.

davidrodway

8th March 2009, 12:12 PM

Interesting article on placebo taken from the osteopathic website Sacral Musings (its quite a fun website and worth a visit but please be aware it gets visited by osteopaths , and non-osteopaths from all over the worl and many different osteopathic colleges (many of the contributors are still students) and so is a bit of a bazzar (or bizarre). You will find many different views on there (and a lot of wind-ups) so take it all with a large pinch of salt

The placebo effect, or response, is the reduction of a symptom, or a change in a physiological parameter, when an inert treatment (the placebo) is administered to a subject who is told that it is an active drug with specific pharmacological properties. The nocebo effect, or response, is a placebo effect in the opposite direction. For example, administration of an inert substance along with verbal suggestions of pain increase may induce a hyperalgesic effect. The placebo effect, so far considered a nuisance in clinical research when a new treatment has to be tested, has now become a target of scientific investigation to better understand the physiological and neurobiological mechanisms that link a complex mental activity to different functions of the body. There is not a single placebo effect but many, which occur through different mechanisms in different conditions, systems and diseases.

Methodological considerations

The identification of a placebo effect is not easy and its study is full of drawbacks and pitfalls. In fact, the effect which follows the administration of a placebo can be due to many factors, such as spontaneous remission (natural history), regression to the mean, symptom detection ambiguity and biases. All these phenomena can be ruled out by means of control groups. Spontaneous remission can be discarded by means of a no-treatment group, which gives us information about the natural course of a symptom. Regression to the mean, a statistical phenomenon whereby a symptom tends to be at its peak at the enrolment in a clinical trial and then tends to the mean of the population at a second measurement, can be controlled by using an experimental model in healthy volunteers. Symptom detection ambiguity and biases can be avoided by using objective physiological measurements. It is also important to rule out the possible effects of co-interventions. When all these phenomena are ruled out, substantial placebo effects can be detected which are mediated by psychophysiological mechanisms. Therefore, it is this psychological component that represents the real placebo effect.

Mechanisms across medical conditions

The placebo effect is basically a context effect, whereby the psychosocial context around the medical intervention plays a crucial role. Today we know that the context may produce a therapeutic effect through at least two mechanisms: conscious anticipatory processes and unconscious conditioning mechanisms. The neural mechanisms underlying the placebo effect are only partially understood and most of our knowledge comes from pain, although recently Parkinson’s disease, immune and endocrine responses, and depression have emerged as interesting models. In each of these conditions, different mechanisms seem to take place, so that we cannot talk of a single placebo effect but many.

As to pain and analgesia, there is today general agreement that the endogenous opioid systems play an important role in some circumstances. There are several lines of evidence indicating that placebo analgesia is mediated by a descending pain modulating circuit which uses endogenous opioids as neuromodulators. This evidence comes from a combination of both imaging and pharmacological studies. For example, by using positron emission tomography (PET), it was found that the very same regions of the brain in the cerebral cortex and in the brainstem are affected by both a placebo and the opioid agonist remifentanil, thus indicating a related mechanism in placebo-induced and opioid-induced analgesia. In other studies with functional magnetic resonance imaging (fMRI), it was shown that placebo administration produces a decrease of activity in many regions involved in pain transmission, such as the thalamus and the insula. The involvement of endogenous opioids in placebo analgesia is shown by several pharmacological studies in which placebo analgesia has been found to be antagonized by the opioid antagonist naloxone. By using in vivo receptor binding, it has been found that placebos induce the activation of mu opioid receptors in different brain areas.

The placebo-activated endogenous opioids do not act only on pain transmission, but on the respiratory centers as well. In fact, a naloxone-reversible placebo respiratory depression has been described. Likewise, a reduction of sympathetic activity, which is blocked by naloxone, has been found during placebo analgesia. These findings indicate that the placebo-activated opioid systems have a broad range of action, influencing pain, respiration and the autonomic nervous system. The placebo-activated endogenous opioids have also been shown to interact with endogenous substances that are involved in pain transmission. For example, on the basis of the anti-opioid action of cholecystokinin (CCK), CCK-antagonists have been shown to enhance placebo analgesia, thus suggesting that the placebo-activated opioid systems are counteracted by CCK during a placebo procedure. It is also important to point out that some types of placebo analgesia appear to be insensitive to naloxone, thus suggesting that neuromodulators other than opioids can be involved in some circumstances.

The release of endogenous substances following a placebo procedure is a phenomenon that is not confined to the field of pain, but it is also present in motor disorders, such as Parkinson’s disease. As occurs with pain, in this case patients are given an inert substance (placebo) and are told that it is an anti-parkinsonian drug that produces an improvement in their motor performance. PET studies show that placebo-induced expectation of motor improvement activates endogenous dopamine in the striatum of Parkinsonian patients. As this occurs in both the dorsal and ventral striatum, a region involved in reward, it has been argued that the expectation-induced release of dopamine in Parkinson’s disease is related to reward mechanisms. Placebo administration in Parkinson patients also affects the activity of the neurons in the subthalamic nucleus, a brain region belonging to the basal ganglia circuitry. In fact, verbal suggestions of motor improvement during a placebo procedure reduce the firing rate and abolish bursting activity of subthalamic nucleus neurons, and these effects are related to clinical improvement.

Placebo responses in both the immune and endocrine system can be evoked by pharmacological conditioning. In fact, after repeated administrations of a drug, if the drug is replaced with a placebo, immune or hormonal responses can be evoked that are similar to those obtained by the previously administered drug. This occurs with immunosuppressive placebo responses, that can be induced by repeated administrations of cyclosporine A (unconditioned stimulus) associated to a flavoured drink (conditioned stimulus). Likewise, if a placebo is given after repeated administrations of sumatriptan, a serotonin agonist of the 5-HT1B/1D receptors that stimulates growth hormone (GH) and inhibits cortisol secretion, a placebo GH increase and a placebo cortisol decrease can be found. These studies support a conditioning mechanism in both immunosuppressive and hormonal placebo responses.

Patients with depression who receive a placebo treatment show both electrical and metabolic changes in the brain. In the first case, placebos induce electroencephalographic changes in the prefrontal cortex of patients with major depression, particularly in the right hemisphere. In the second case, changes in brain glucose metabolism were found in several brain regions in subjects with unipolar depression.

Nocebo effect

Due to ethical limitations, the mechanisms of the nocebo effect are less understood. Anticipatory anxiety may play a fundamental role. Nocebo hyperalgesia has been found to be blocked by proglumide, a nonspecific CCK-A/CCK-B receptor antagonist. This suggests that expectation-induced hyperalgesia is mediated, at least in part, by CCK. These effects of proglumide are not antagonized by naloxone, thus endogenous opioids are not involved.

Clinical implications

According to the classical methodology of clinical trials, any drug must be compared with a placebo in order to assess its effectiveness. If the group that receives the drug shows a larger clinical improvement than the group that receives the placebo, the drug is considered to be effective. However, in light of the recent advances in placebo research, some caution is necessary in the interpretation of some clinical trials. In fact, by taking into account the cascade of biochemical events induced by placebo administration, any drug that is tested in a clinical trial may interfere with these placebo-activated mechanisms, thus confounding the interpretation of the outcome of the clinical trial. As we have no a priori knowledge of which substances act on placebo-activated endogenous opioids or dopamine — and indeed almost all drugs might interfere with these neurotransmitters — one way to eliminate this possible pharmacological interference is to make the placebo-activated biochemical pathways ‘silent’. This can be achieved by the hidden administration of drugs.

Hidden administration of drugs

It is possible to eliminate the placebo (psychosocial) component and analyse the pharmacodynamic effects of a treatment, free of any psychological contamination, by administering drugs covertly. In this way, the cascade of biochemical events triggered by a placebo procedure can be eliminated. To do this, the patient is not made aware that a medical therapy is being carried out. To make this possible, drugs are administered through hidden infusions by machines. A hidden drug infusion can be performed through a computer-controlled infusion pump that is pre-programmed to deliver the drug at the desired time. It is crucial that the patient does not know that any drug is being injected, so that he does not expect anything.

The analysis of different treatments has shown that an open (expected) therapy, that is carried out in full view of the patient, is more effective than a hidden one (unexpected). Whereas the hidden injection represents the real pharmacodynamic effect of the drug, free of any psychological contamination, the open injection represents the sum of the pharmacodynamic effect plus the psychological component of the treatment. The latter can be considered to represent the placebo component of the therapy, even though no placebo has been given. It is important to realize that, by using hidden administration of drugs, it is possible to study the placebo effect without the administration of any placebo.

davidrodway

8th March 2009, 12:43 PM

http://api.ning.com/files/me81N4R8uxuZE254fECRAEStJiEMgoQoUy1y6NLiPI8IS7AM6v 1fcszCxAoPFND-qIOat7H*hfWeBpasuAirBwtuL2BS7lfk/thorazsenile.jpg

The ad reads:

Doctor, what can you do for Pop?

Deeply involved in the problem of the hostile, agitated senile are members of the family... and you, their physician.

In discussing the use of 'Thorazine', Pollack(1) observes:

"Older persons with such disorders can be treated at home by the general practitioner with much benefit and with great relief to the family." With 'Thorazine', senile patients become calm, agreeable and sociable. They begin to eat and sleep better, often gain weight and improve physically. for prompt control of the agitated, belligerent senile...

THORAZINE*

Ampuls for immediate effect -- carry them in your bag
Also available: Tablets, Syrup and Suppositories
Smith, Kline & French Laboratories, Philadelphia
1. Pollack, B.: Geriatrics 11:253 (June) 1956.
*T.M. Reg. U.S. Pat. Off. for chlorpromazine. S.K.F

davidrodway

8th March 2009, 12:56 PM

[quote=Blue Wode;37442]Here is the website of The British Institute of Osteopathy - a ‘recognising’ body as opposed to a registering body.
http://www.british-institute-of-osteopathy.org/Default.aspx

For the record the so called BIO is run by a osteopath called Howard Beardmore (not Broadmoor),. I think he may even be the only member of this Institute. I often crooss swords with him on the OFA forum. If any other osteopaths agree with him I would think they represent about ten people out of a profession of about 4000 in the UK. Even worse, he is a closet Deep Purple fan.

davidrodway

8th March 2009, 01:02 PM

davidrodway

8th March 2009, 01:08 PM

That's as maybe but if that's the case why aren't they willing to clean house to get rid of the 'minority' of quacks?

Theres actually a revalidation coming up organised by the GOsC. Not sure what form it will take, but i i hope it will get rid of a few bad apples.

davidrodway

8th March 2009, 01:13 PM

davidrodway

8th March 2009, 01:18 PM

DD - I accept that a minority of osteopaths and chiropractors don't follow the wackier side of things but is there anything, at the end of the day, that separates them from a good physiotherapist?

Some physios use manual techniqwues but they are usually learned post grad wheras osteopaths start hands on practice (nmot on patients at first) from day one and thru the four year course, Most physio manual stuff is Maitland, who copied his technques from osteopaths apparently (so its a bit second or even third hand). Physios mostly use machines and exercise. Also osteopaths are trained to be firstr-contact practioners so they are trained in history taking and clinical methods to make a diagnosis and recognise pathology that needs to be refferd on.

davidrodway

8th March 2009, 01:33 PM

davidrodway

8th March 2009, 01:39 PM

[quote=Neuromuscular Therapist;44706]I completely agree. In my practice I use more than just one mode. In my practice I regularly use MET (Muscle Energy Technique), STR (Soft Tissue Release), Myofascial Release, Strain, Counter strain, Positional Release and Neuromuscular Technique, which is working to locate and de-activate Trigger Points. I use a mixture of techniques, according to the client in front of me, what their problem is and their needs.

[\quote]

Muscle energy technique
Soft tissue release
Myofascial release
Positional release

Nice terms: do they simply describe what you do, or the impact in the body, if the latter any evidence base? How do you know that the muscle energy technique does something to the metabolism of the muscle, if so what how much, for how long etc?

Muuscle energy technique is really a misnomer. ITs getting the muscle to contract against the operator resistance (not full force) so that the antagonist reflexly relaxes. You can do a crude demonstration of this on yourself - if place your hand on the side of your face and then trying rotating your neck to that side against the resistance for a few seconds, you will probably notice that for a short while afterward your head turns more easily to that side than the other.

davidrodway

8th March 2009, 01:43 PM

Thanks for this. Quite a bit to work through, so I will probably bite off just one section to try and get the original information to report back on. Superficially, the impression is of little evidence of signficant benefit from the better conducted trials, but general support for the exercise/posture based approach rather than passive (massage) approach.

MCKenzie is a physio I think, not an osteopath - certainly exercise based not hands on

davidrodway

8th March 2009, 02:03 PM

The jump from a specific condition or a single case to a general principle, and the idea that a single basic treatment can cure any condition, is fairly characteristic of "woo", for example:

Cinchona bark treats malaria, and Hahnemann experienced fever-like symptoms after taking Cinchona bark, therefore any disease can be treated by something that produces its symptoms
Spinal manipulation appeared to restore a man's hearing, therefore any disease can be treated by spinal manipulations
Foot massages feel nice, so any condition can be treated by massaging the soles of the feet.
Similarly, the idea that all diseases have a single basic cause:

Obstruction of nerve signals (e.g. chiropractic)
Psora or Miasms (homoeopathy)
obstruction of the flow of Qi along meridians (TCM)
Imbalance of "humours" (Ayurveda, 18th century "allopathy")
A slightly less sweeping example: all cancers are caused by liver flukes.

THe spinal manip to cure hearing claim is actusally chiropractic. Yes, AT Still thought he had found a panacea - a universal cure for all ills. He was wrong (see my previous post). That was back in 1875

davidrodway

8th March 2009, 02:22 PM

Some Research:

Research
Research is vital to assess the efficacy of osteopathic treatment and further a knowledge base on which to enhance patient care and rational osteopathic practice.

Osteopathic research has grown in recent years, spurred on in part by the annual International Conference of Osteopathic Research that started ten years ago, and whose proceedings are printed in the International Journal of Osteopathic Medicine. A research ethos is encouraged in the undergraduates at the osteopathic colleges.

To help establish an evidence base the GOsC has helped to establish and part fund the National Council for Osteopathic Research (NCOR). This is an independent body, whose remit is to encourage and develop a research culture within the field of osteopathy.

The NCOR consists of representatives from GOsC, the osteopathic educational institutions, the British Osteopathic Association,(www.osteopathy.org) the NHS and private practitioners. It is chaired by Professor Ann Moore who is Director of the Clinical Research Centre forHealthProfessions (www.brighton.ac.uk/sohp/research/) at the University of Brighton. It has established research hubs throughout the UK where practicing osteopaths assemble to discuss and help implement research projects. For further information contact the Research Development Officer for NCOR or visit their website at www.ncor.org.uk.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF CHRONICNON-SPECIFIC LOW BACK PAIN

Summary of the concepts of treatment of chronic low back pain (CLBP)

• Conservative treatments:Cognitive behavioural therapy, exercise therapy, brief educational interventions,and multidisciplinary (bio-psycho-social) treatment can each be recommendedfor non-specific CLBP. Back schools, and short courses of manipulation canalso be considered. The use of physical therapy (TENS, heat/cold, traction,laser, ultrasound, short wave, interferential, massage, corsets) cannot be
recommended.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARESummary of recommendations for treatment of acute non-specific low back pain:
Consider (referral for) spinal manipulation for patients who are failing to return to normal activities

The musclulo-skeletal services framework. Published by the DOH in 2006 which suggests developing capacity in primary care including osteopathy.Welsh Back CampaignTaken from www.welshbacks.com Advice for health professionalsManagement of acute mechanical low back painIf failing to return to normal activities: Reassess to exclude serious pathology • Consider a short course of manipulation • Address beliefs/behaviours that may be delaying recovery Designed for People with Chronic Conditions Service Development and Commissioning Directives Chronic Non-Malignant Pain 4.4 Effective acute pain managementPossible solution:An example of how primary care could provide for early identification and management of red and yellow flags would be an acute back pain clinic. People with acute back pain could present for assessment, simple advice and treatment according to the evidence based guidelines. These centres could be run by appropriately trained nurses, physiotherapists, osteopaths and chiropractors. They could operate on a 6 treatment basis in liaison with the GP who could then seek other treatment avenues should ongoing treatment be required. 1. Systematic reviews and meta-analysis In 2005 a meta-analysis of osteopathic manipulative treatment for LBP was carried out.Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials BMC Musculoskeletal Disorders 2005, 6:43 doi:10.1186/1471-2474-6-43 Results: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 – -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow up.
Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004 May-Jun;4(3):335-56.

cONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP.Non pharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):492-504.CONCLUSIONS: Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.
British School of Osteopathy

journal PublicationsAbbey, H. (2008). ‘Assessing Clinical Competence in Osteopathic Education; analysis of outcomes of different assessment strategies at the British School of Osteopathy.’ International Journal of Osteopathic Medicine, 11 (4): 125-131.Brownhill, K. (2007). ‘Back pain and the homoeostatic requirements of the spinal system.’ International Journal of Osteopathic Medicine, 10 (1): 18-23.London, S. (2008). ‘The assessment of clinical practice in osteopathic education: Is there a need to define a gold standard?’ International Journal of Osteopathic Medicine 11 (4): 132-136.Parsons, S, Breen, A, Foster, N, Letley, L, Pincus, T, Vogel, S & Underwood, M. (2007). ‘Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations.’ Family Practice 24 (4):308-16.Pincus, T, Santos, R et al. (2007). ‘Depressed cognitions in chronic pain patients are focused on health: evidence from a sentence completion task.’ Pain 130 (1-2): 84-92.Pincus, T, Ruso, A & Santos, R. (2008). “Responsiveness and construct validity of the Depression, Anxiety and Positive Outlook Scale (DAPOS)” Clinical Journal of Pain. 24 (5):431-7.Pincus, T, Santos, R, Breen, A, Burton, K & Underwood, M. (2007). “A review and proposal for a core set of factors for prospective cohorts in low back pain; the MMICS Statement.” Arthritis Care & Research, Arthritis and Rheumatism 28; 59 (1):14-24.Tyreman, S. (2007). ‘It's Illness, But Is It Mental Disorder?’
Philosophy, Psychiatry & Psychology – 14 (2): 103-106.Tyreman, S. (2008). ‘Valuing osteopathy: What are (our) professional values and how do we teach them?’ International Journal of Osteopathic Medicine 11 (3): 90-95.Tyreman, S. (2008). ‘Commentary on Is there a place for science in the definition of osteopathy?’ International Journal of Osteopathic Medicine 11 (3): 102-105.Zamani, J, Vogel, S, Moore, A & Lucas, K. (2007). ‘Analysis of exercise content in undergraduate osteopathic education - A content analysis of UK curricula.’ International Journal of Osteopathic Medicine 10 (4): 97-103.
Published journal paper reviews
Abbey, H. (2008). ‘Psychosocial predictors of chronicity in low back pain’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Abbey, H. (2008). ‘Who uses CAM in Canada for back pain?’ International Journal of Osteopathic Medicine, 11 (3): 114-119.Abbey, H. (2008). ‘Psychosocial differences between acute and chronic low back pain patients’ International Journal of Osteopathic Medicine, 11 (3): 114-119.Abbey, H. (2008). ‘Do beliefs about back pain relate to pain experiences and contact with health professionals in Norway?’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Abbey, H. (2008). ‘Who gets what? A new screening tool to identify patient subgroups for back pain treatment allocation in primary care’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Blanchard, P. (2008). ‘Orthopaedic tests of the shoulder – are they accurate?’ International Journal of Osteopathic Medicine, 11 (2): 71-75. Blanchard, P. (2008). ‘Referred and nerve root pain arising from the low back – are they two distinct entities?’ International Journal of Osteopathic Medicine, 11 (2): 71-75. Blanchard, P. (2008). ‘Are there predictive rules for the development of adverse events following chiropractic care for patients with neck pain?’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Evans, D. (2008). ‘Persistent sciatica creates widespread sensitivity to further noxious stimuli’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Evans, D. (2008). ‘Persistent neck pain – what hurts and where?’ International Journal of Osteopathic Medicine, 11 (3): 114-119.

Morrison, R. (2008). ‘Physiotherapy education: using simulated patients an evidence-based model’ International Journal of Osteopathic Medicine, 11 (3): 114-119.Parry, C. (2008). ‘The role of red flags in musculoskeletal pain presentations’ International Journal of Osteopathic Medicine, 11 (1): 34-38.

Parry, C. (2008). ‘Night pain in back pain triage: what is its significance?’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Pincus, T. (2008). ‘Pain, ethnicity, race and culture: more research needed’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Tyreman, S. (2008). ‘Influence of a postgraduate clinical master’s qualification in manual therapy on the careers of physiotherapists in the United Kingdom’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Vogel, S. (2008). ‘Adverse events round up’ International Journal of Osteopathic Medicine, 11 (2): 71-75. Zamani, J. (2008). ‘What influences physiotherapists to undertake Masters Level Study?’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)

EUROPEAN GUIDELINESFOR THE MANAGEMENT OF CHRONICNON-SPECIFIC LOW BACK References1. Abenhaim L, Bergeron AM (1992) Twenty years of randomized clinical trials ofmanipulative therapy for back pain: a review. Clin Invest Med, 15(6): 527-35.2. Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A (1992) A metaanalysisof clinical trials of spinal manipulation. J Manipulative Physiol Ther, 15(3):181-94.3. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S (1999) Acomparison of osteopathic spinal manipulation with standard care for patients withlow back pain. N Engl J Med, 341(1426-1431).4. Assendelft WJ, Koes BW, van der Heijden GJ, Bouter LM (1992) The efficacy ofchiropractic manipulation for back pain: blinded review of relevant randomizedclinical trials. J Manipulative Physiol Ther, 15(8): 487-94.5. Assendelft WJ, Koes BW, van der Heijden GJ, Bouter LM (1996) Theeffectiveness of chiropractic for treatment of low back pain: an update and attempt atstatistical pooling. J Manipulative Physiol Ther, 19(8): 499-507.6. Assendelft WJ, Lankhorst GJ (1998) [Effectiveness of manipulative therapy in lowback pain: systematic literature reviews and guidelines are inconclusive]. NedTijdschr Geneeskd, 142(13): 684-7.7. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2003) Spinalmanipulative therapy for low back pain. A meta-analysis of effectiveness relative toother therapies. Ann Intern Med, 138(11): 871-81.8. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004) Spinalmanipulative therapy for low-back pain (Cochrane Review). In: The CochraneLibrary, Issue 3. John Wiley & Sons, Ltd.: Chichester, UK.9. Aure OF, Nilsen JH, Vasseljen O (2003) Manual therapy and exercise therapy inpatients with chronic low back pain: a randomized, controlled trial with 1-year followup.Spine, 28(6): 525-31; discussion 31-2.10. Bronfort G (1999) Spinal manipulation: current state of research and itsindications. Neurol Clin, 17(1): 91-111.11. Bronfort G, Goldsmith CH, Nelson CF, Boline PD, Anderson AV (1996) Trunkexercise combined with spinal manipulative or NSAID therapy for chronic low backpain: a randomized, observer-blinded clinical trial. J Manipulative Physiol Ther, 19(9):570-82.12. Brox JI, Hagen KB, Juel NG, Storheim K (1999) [Is exercise therapy andmanipulation effective in low back pain?]. Tidsskr Nor Laegeforen, 119(14): 2042-50.13. Cassidy JD, Thiel HW, Kirkaldy-Willis WH (1993) Side posture manipulation forlumbar intervertebral disk herniation. J Manipulative Physiol Ther, 16(2): 96-103.14. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG (2003) A review of theevidence for the effectiveness, safety, and cost of acupuncture, massage therapy,and spinal manipulation for back pain. Ann Intern Med, 138(11): 898-906.15. Chiradejnant A, Maher CG, Latimer J, Stepkovitch N (2003) Efficacy of "therapistselected"versus "randomly selected" mobilisation techniques for the treatment of lowback pain: a randomised controlled trial. Aust J Physiother, 49(4): 233-41.16. CMAJ (Oct 2004). Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ (2001)Chiropractic technique procedures for specific low back conditions: characterizing theliterature. J Manipulative Physiol Ther, 24(6): 407-24.18. Ernst E (2001) Prospective investigations into the safety of spinal manipulation. JPain Symptom Manage, 21(3): 238-42.9919. Ernst E, Harkness E (2001) Spinal manipulation: a systematic review of shamcontrolled,double-blind, randomized clinical trials. J Pain Symptom Manage, 22(4):879-89.20. Evans DP, Burch MS, K.N. L, Roberts EE, Roberts GM (1978) Lumbar spinalmanipulation on trial. Part 1: Clinical assessment. Rheumatol Rehabil, 17: 46-53.21. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG (2002) Does spinalmanipulative therapy help people with chronic low back pain? Aust J Physiother,48(4): 277-84.22. Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ (2001) Ratingspecific chiropractic technique procedures for common low back conditions. JManipulative Physiol Ther, 24(7): 449-56.23. Gibson T, Grahame R, Harkness J, Woo P, Blagrave P, Hills R (1985) Controlledcomparison of short-wave diathermy treatment with osteopathic treatment in nonspecificlow back pain. Lancet, 1(8440): 1258-61.24. Harvey E, Burton AK, Klaber Moffett J, Breen A (2003) Spinal manipulation forlow back pain: a treatment package agreed by the UK chiropractic, osteopathy andphysiotherapy professional associations. Manual Therapy, 8: 46-51.25. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P (1997) Does folkmedicine work? A randomized clinical trial on patients with prolonged back pain. ArchPhys Med Rehabil, 78(6): 571-7.26. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P (2002) Longtermeffectiveness of bone-setting, light exercise therapy, and physiotherapy forprolonged back pain: a randomized controlled trial. J Manipulative Physiol Ther,25(2): 99-104.27. Herzog W, Conway PJW, Wilcox BJ (1991) Effects of different treatmentmodalities on gait symmetry and clinical measures for sacroiliac joint patients. JManipulative Physiol Ther, 14: 104-9.28. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Belin TR, Yu F, Adams AH(2002) A randomized trial of medical care with and without physical therapy andchiropractic care with and without physical modalities for patients with low back pain:6-month follow-up outcomes from the UCLA low back pain study. Spine, 27(20):2193-204.29. Koes B, Bouter L, H vM, Essers A, Verstegen G, Hofhuizen D, Houben J,Knipschild P (1992) The effectiveness of manual therapy, physiotherapy, andtreatment by the general practitioner for nonspecific back and neck complaints: Arandomized clinical tria. Spine, 17(1): 28-35.30. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM (1996) Spinalmanipulation for low back pain. An updated systematic review of randomized clinicaltrials. Spine, 21(24): 2860-71; discussion 72-3.31. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM, Knipschild PG (1991)Spinal manipulation and mobilisation for back and neck pain: a blinded review. Bmj,303(6813): 1298-303.32. Leboeuf-Yde C, Hennius B, Rudberg E, Leufvenmark P, Thunman M (1997) Sideeffects of chiropractic treatment: a prospective study. J Manipulative Physiol Ther,20(8): 511-5.33. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, Swift J, Jr. (2003)Osteopathic manipulative treatment for chronic low back pain: a randomizedcontrolled trial. Spine, 28(13): 1355-62.34. Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren K-A, Sarna S, Hurri H(2003) A randomized trial of combined manipulation, stabilising exercises, andphysician consultation compared to physician consultation alone for chronic low backpain. Spine, 28(19): 2185-91.35. Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ (1987) A new approach tothe treatment of chronic low back pain. Lancet, 2(8551): 143-6.36. Ottenbacher K, DiFabio RP (1985) Efficacy of spinal manipulation/mobilizationtherapy. A meta-analysis. Spine, 10(9): 833-7.10037

davidrodway

8th March 2009, 02:23 PM

And some more (Dont know why those smilies are there, sorry).

Pope MH, Phillips RB, Haugh LD, Hsieh CY, MacDonald L, Haldeman S (1994) Aprospective randomized three-week trial of spinal manipulation, transcutaneousmuscle stimulation, massage and corset in the treatment of subacute low back pain.Spine, 19(22): 2571-7.38. Postacchini F, Facchini M, Palieri P (1988) Efficacy of various forms ofconservative treatment in low back pain: a comparative study. Neurol Orthop, 6: 113-6.39. Pustaver MR (1994) Mechanical low back pain: etiology and conservativemanagement. J Manipulative Physiol Ther, 17(6): 376-84.40. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I (2003) Stabilizing trainingcompared with manual treatment in sub-acute and chronic low-back pain. Man Ther,8(4): 233-41.41. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH (1992) Spinalmanipulation for low-back pain. Ann Intern Med, 117(7): 590-8.42. Shekelle PG, Coulter I, Hurwitz EL, Genovese B, Adams AH, Mior SA, Brook RH(1998) Congruence between decisions to initiate chiropractic spinal manipulation forlow back pain and appropriateness criteria in North America. Ann Intern Med, 129(1):9-17.43. Skargren E, Oberg B, Carlsson P, Gade M (1997) Cost and EffectivenessAnalysis of Chiropractic and Physiotherapy Treatment for Low Back and Neck Pain.Six-Month Follow-Up. Spine, 22(18): 2167-77.44. Stevinson C, Ernst E (2002) Risks associated with spinal manipulation. Am JMed, 112(7): 566-71.45. Timm KE (1994) A randomized-control study of active and passive treatments forchronic low back pain following L5 laminectomy. J Orthop Sports Phys Ther, 20(6):276-86.46. Triano JJ, McGregor M, Hondras MA, Brennan PC (1995) Manipulative therapyversus education programs in chronic low back pain. Spine, 20(8): 948-55.47. UK BEAM Trial Team. Brealey S, Coulton S, Farrin A, Morton V, Torgerson D,Burton AK, Garratt A, Harvey E, Letley L, Martin J, Vickers M, Whyte K, Manca A,Klaber Moffett J, Russell I, Underwood M, Williams M (2004a) United Kingdom backpain exercise and manipulation (UK BEAM) randomised trial: Cost-effectiveness ofphysical treatments for back pain in primary care. British Medical Journal,329(7479):138148. UK BEAM Trial Team. Brealey S, Coulton S, Farrin A, Morton V, Torgerson D,Burton AK, Garratt A, Harvey E, Letley L, Martin J, Vickers M, Whyte K, Manca A,Klaber Moffett J, Russell I, Underwood M, Williams M (2004b) United Kingdom backpain exercise and manipulation (UK BEAM) randomised trial: effectiveness ofphysical treatments for back pain in primary care. British Medical Journal,329(7479):137749. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM (1997) Method guidelinesfor systematic reviews in the Cochrane Collaboration Back Review Group for SpinalDisorders. Spine, 22(20): 2323-30.
50. Waagen GN, Haldeman S, Cook

Blue Wode

8th March 2009, 03:03 PM

David Rodway wrote:

Nice point about “cranial” and the GOsC Code. I think that the response would be (But why not ask the GOsC directly?) that, if challenged, the “cranial” osteopath would say that they believe (and they really will) that what they are doing is in the patients best interests.
All of which fits in nicely with what Rose Shapiro writes on p.130 of her book, Suckers: Why alternative medicine makes fools of us all:

Osteopathy and chiropractic have both managed to gain huge respectability simply by being officially regulated, despite there being no official standards of efficacy for either practice. State regulation is equated with state approval, hence they go largely unquestioned and uncriticised.
David Rodway wrote:

Ernst says it is his reading of it [the BEAM trial]. So I assume there are others that vary. Interestingly he says (I think) that he thinks that touch enhances the benefits of exercise . Or is it exercise enhances the benefits of touch. Are we talking, all touch, any touch, touch by osteopaths, touch by physios? Is touch by osteopaths better than touch by physios.? A lot of the benefit of osteopathy is because of touch - that is the point. Doesn’t mean that just getting your husband/wife to toch you is going to be as beneficial for your health/pain as an osteopaths touch (although it might be)
Here’s Ernst on ‘touch’:

Some believe the power of touch is all down to the placebo effect. "If you touch your partner they feel relaxed, but if someone else touches they may not feel as relaxed," said Professor Edzard Ernst, a professor of complementary medicine at the University of Exeter. "That is very much mind over matter. It has nothing to with the sensations of being touched, it is the expectation and the context of the intervention, rather than the specific effect of that intervention."
http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/how-the-power-of-touch-reduces-pain-and-even-fights-disease-419462.html (http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/how-the-power-of-touch-reduces-pain-and-even-fights-disease-419462.html)

David Rodway wrote:

Neck treatment. Not sure of the source of your neck exercise is best quote. What neck exercises anyway?
See here:

…neck pain is not a life-threatening condition, it is often a self-limiting complaint, and treatments exist that are devoid of risk.
-snip-
There is general agreement (supported by data) that Cochrane reviews are of the highest quality and thus contribute the most definitive evidence. The Cochrane review on the present topic had very broad inclusion criteria (e.g. including trials with multi-modal interventions),2 (http://www.medicinescomplete.com/journals/fact/current/fact0902a06d01.htm#fact0902a06d01v02b0002) thus we have to be very careful when citing it specifically in relation to spinal manipulation. In its results section, the reviewers dedicate several paragraphs to the heading ‘manipulation alone’. These make very clear statements: ‘Four RCTs assessed the effect of a single session of manipulation. When compared to a control there was moderate evidence that single sessions did not result in short-term pain relief … Five trials assessed the effect of 6–20 sessions of manipulation … against various comparisons … In every case, the results were negative … Three trials found no difference in short- and intermediate-term pain relief when manipulation was compared to mobilisation …’ This important piece of evidence is often misquoted. It yields positive results for ‘multimodal therapy’, e.g. manipulation plus mobilisation or exercise or physical therapies such as heart application. Proponents of spinal manipulation therefore tend to represent this as positive evidence for their therapy. This is not correct!

Proponents of spinal manipulation will rightly point out that the absence of evidence is not the same as evidence of absence of an effect. On the other hand, critical thinkers would argue that, even if an effect can one day be demonstrated, it could be due to a placebo response.3 (http://www.medicinescomplete.com/journals/fact/current/fact0902a06d01.htm#fact0902a06d01v02b0003) Spinal manipulation has several of the characteristics that make a ‘powerful placebo’. But who cares? Does it really matter whether a patient gets better because of a specific or a non-specific response? Perhaps not from a practical, clinical point of view – provided the placebo is safe!

The references are listed here:
http://www.medicinescomplete.com/journals/fact/current/fact0902a06d01.htm (http://www.medicinescomplete.com/journals/fact/current/fact0902a06d01.htm)

David Rodway wrote:

I should also add that before an LAHVT we will test eg auscultate for carotid bruit. Also the history may point against LAHVT – eg drop attacks, clotting disorders – in which case no LAHVT is done.
That’s still not very reassuring considering the following:

Some therapists have started advocating screening patients for risk factors before treatment.55 (http://jrsm.rsmjournals.com/cgi/content/full/100/7/330#REF55#REF55)-57 (http://jrsm.rsmjournals.com/cgi/content/full/100/7/330#REF57#REF57) Based on cadaver studies of human vertebral arteries, Cagnie et al.58 (http://jrsm.rsmjournals.com/cgi/content/full/100/7/330#REF58#REF58) have suggested that, in the presence of arteriosclerotic changes, the stretching and compression effects of rotational manipulation may constitute a risk factor for vascular accidents. These authors concluded that ‘therapists should avoid manipulative techniques at all levels of the cervical spine in the presence of any indirect sign of arteriosclerotic disease or in the presence of calcified arterial walls or tortuosities of the vessel.’58 (http://jrsm.rsmjournals.com/cgi/content/full/100/7/330#REF58#REF58) Others have suggested that high homocystein levels constitute a risk factor for arterial dissection.59 (http://jrsm.rsmjournals.com/cgi/content/full/100/7/330#REF59#REF59) Spinal manipulation might therefore be contraindicated in such individuals. The effectiveness of screening has, however, not been convincingly demonstrated.
Adverse effects of spinal manipulation: a systematic review
http://jrsm.rsmjournals.com/cgi/content/full/100/7/330 (http://jrsm.rsmjournals.com/cgi/content/full/100/7/330)

In the absence of neurologic symptoms, there is no reliable way to predict which patients are at risk of stroke.

-snip-

…what about the patients who present for care with no symptoms of CAD and without even complaining of head or neck pain? Stroke victims are clearly NOT just patients who went to a chiropractor with head or neck pain. Some were being treated for things like low back pain or shoulder pain. Some patients like Sandra Nette had no pain at all: she had a catastrophic stroke after neck manipulation done simply for health maintenance purposes. Laurie Jean Mathiason, a 20 year old woman, received 186 manipulations of her neck over a 6 month period when her original complaint was lower back pain. The 186th one killed her.
http://www.sciencebasedmedicine.org/?p=362 (http://www.sciencebasedmedicine.org/?p=362)

David Rodway wrote:

Ernst – not decrying him completely, just saying he is not the sole authority. For example (without looking it up again ) I think there was something in that advice he gave in the Daily Mail about making sure that the osteopath would not use vigorous treatment if the patient told them they had cancer, bone infection, clotting disorders and some others. This implies he does not realise that an osteopath will know not to use certain techniques if these conditions are present.
He’s probably erring on the side of caution since it's apparent that some osteopaths are deluded enough to use quackery such as craniosacral therapy/cranial osteopathy on their patients.

David Rodway wrote:

Point is, why doesn’t Ernst know that is what is what we do? Should he not visit a few osteopathic colleges?. He can come to my practice if he likes and watch me work.
One has to assume that Ernst is very familiar with what you do when you consider that he was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty,
http://www.newscientist.com/article/mg19826531.400-interview-the-complementary-medicine-detective.html?page=2 (http://www.newscientist.com/article/mg19826531.400-interview-the-complementary-medicine-detective.html?page=2)
and that he has also been trained in spinal manipulation and has applied it clinically. See the end of his Systematic review of case reports of serious adverse events following manipulation of the cervical spine (1995–2001) here:
http://www.mja.com.au/public/issues/176_08_150402/ern10520_fm.html (http://www.mja.com.au/public/issues/176_08_150402/ern10520_fm.html)

David Rodway wrote:

Ernst impartial – trouble is he doesn’t do research of his own as far as I know. And he has overlooked some that has been done (references to folllow as I said before}

Who should do research –If osteopaths do it the results are “biased”, if we do not do it we are criticised for not doing our own research If we use other peoples results we are “piggy backing”. Cant win .l I think osteopaths and non-osteopaths should do the research and then the studies stand on their own merits.
It’s not up to Ernst to do the research; rather it is the responsibility of the proponents who make the claims. Ernst’s job is to evaluate the emerging evidence for CAM from a scientific point of view. What could be fairer than that?

BTW, re the cost-effectiveness of osteopathy. The following review from 2006 might be of interest to you,

Prospective, controlled, cost-effectiveness studies of complementary therapies have been carried out in the UK only for spinal manipulation (four studies) and acupuncture (two studies). The limited data available indicate that the use of these therapies usually represents an additional cost to conventional treatment.
Cost-Effectiveness of Complementary Therapies in the United Kingdom—A Systematic Review
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17173105 (http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17173105)

And this as well:

One controlled study of a medical osteopathy service found that service users did not decrease their use of NHS resources.
The impact of NHS based complementary therapy services on health outcomes and NHS costs: A review of service audits and evaluations
http://7thspace.com/headlines/304871/the_impact_of_nhs_based_complementary_therapy_serv ices_on_health_outcomes_and_nhs_costs_a_review_of_ service_audits_and_evaluations.html (http://7thspace.com/headlines/304871/the_impact_of_nhs_based_complementary_therapy_serv ices_on_health_outcomes_and_nhs_costs_a_review_of_ service_audits_and_evaluations.html)

Blue Wode

8th March 2009, 03:04 PM

David Rodway wrote:

sceptic has a c in it not a bloody k
It’s deliberate. John Jackson, the founder of UK Skeptics, has previously explained the reasons for the use of a ‘k’ instead of ‘c’. A search of the forum should unearth the relevant post.

Pebble wrote:

Woo:

http://www.osteopathy.ie/history.htm (http://www.osteopathy.ie/history.htm)

He believed that the human body was self-healing (Hippocrates thought this somewhat earlier), and that uninterrupted nerve and blood supply to all the tissues of the body was indispensable to their normal function (even Galen thought this though for the wrong reasons). If any structural problem, e.g. muscle spasm, curvature of the spine, etc. interfered with the nerve and blood flow (blood flow and minor spinal abnormalities?), the self healing power was interfered with, and disease would result. With this in mind, he worked out a system of manipulation/adjustment intended to re-align any structural deviations and abnormalities.

So individuals with kyphoscoliosis must have very poor healing abilities! Clearly recovery from colds and sinus disorders must be very delayed in such individuals

Some more on the woo origins of osteopathy from Rose Shapiro on p.134 of her book:

Famously, at ten in the morning on June 22, 1874, Andrew Taylor Still had a ‘prophetic vision’ where he was shot, as he described in his autobiography, ‘not in the heart, but in the dome of reason’ where ‘like a burst of sunshine the whole truth dawned upon my mind’. This truth was that ‘ there was no such disease as fever, flux diphtheria, typhus, typhoid, lung-fever, or any other fever classed und the common head of fever of rheumatism, sciatica gout, colic, liver disease, nettle-rash, or croup, on to the end of the list, they do not exist as diseases’. Instead ‘all diseases are mere effects, the cause being a partial or complete failure of the nerves’, brought about by misalignments of the vertebrae.

As for the current evidence on osteopathy, it includes the following which, once again, I have lifted from Rose Shapiro’s book (p.132):

Osteopathy and chiropractic may be popular with patients the world over, but make enquiries beyond reports of customer satisfaction and there is minimal evidence to show that spinal manipulation is any better at alleviating back pain than gentle exercise. In a review of current research that enraged osteopaths and chiropractors, leading sceptic Professor Edzard Ernst concluded that there was no evidence to suggest that spinal manipulation was an effective intervention for any condition. This finding applies to both osteopathy and chiropractic.
A systematic review of systematic reviews of spinal manipulation (2006)
http://www.jrsm.org/cgi/content/full/99/4/192 (http://www.jrsm.org/cgi/content/full/99/4/192)

Similar conclusions were reached by Dr Scott Kinkade of the University of Texas in another research review. He concluded that manipulative therapy might provide short-term benefits compared with sham therapy, but not when it was compared with conventional treatments including painkillers, anti-inflammatories, heat treatments and advice to stay active.
Evaluation and Treatment of Acute Low Back Pain, American Family Physician (2007)
http://www.aafp.org/afp/20070415/1181.html (http://www.aafp.org/afp/20070415/1181.html)

And from p.135:

In the years since Still’s death osteopathy may have attained the highest status of all fringe medical practices, but the most recent review of the evidence for spinal manipulative therapy as a treatment for lower-back pain found ‘it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner’.
http://www.cochrane.org/reviews/en/ab000447.html (http://www.cochrane.org/reviews/en/ab000447.html)

David Rodway wrote:

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF CHRONICNON-SPECIFIC LOW BACK PAIN

Summary of the concepts of treatment of chronic low back pain (CLBP)

• Conservative treatments:Cognitive behavioural therapy, exercise therapy, brief educational interventions,and multidisciplinary (bio-psycho-social) treatment can each be recommendedfor non-specific CLBP. Back schools, and short courses of manipulation canalso be considered. The use of physical therapy (TENS, heat/cold, traction,laser, ultrasound, short wave, interferential, massage, corsets) cannot be
recommended.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARESummary of recommendations for treatment of acute non-specific low back pain:
Consider (referral for) spinal manipulation for patients who are failing to return to normal activities.
Bearing in mind what the most up-to-date Cochrane review has to say about spinal manipulation for back pain (see above), here’s Ernst’s thoughts on guidelines…

…guidelines are well known to be influenced by the people who serve on the panel that develops them. Cochrane reviews, on the other hand, are generally considered to be objective and rigorous. Writing about the importance of systematic reviews for health care in the Lancet, Sir Ian Chalmers stated, ‘I challenge decision makers within those spheres who continue to frustrate efforts to promote this form of research to come out from behind their closed doors and defend their attitudes and policies in public. There is now plenty of evidence to show how patients are suffering unnecessarily as a result of their persuasive influence.’ 10
http://www.medicinescomplete.com/journals/fact/current/fact1002a02t01.htm (http://www.medicinescomplete.com/journals/fact/current/fact1002a02t01.htm)

Pebble

8th March 2009, 03:13 PM

The summary on placebo effect contains many facts, assumptions and ends with unjustifiable conclusions.

In placebo controlled trials the patient is not duped into believing that they are being administered active therapies. They are specifically informed that they have a 50/50 or occasionally 25/75 chance of receiving inactive therapy.

Thus to properly study the placebo effect one must also analyse the response of people who are not necessarily of the opinion that the pill is active.

Second the regression to the mean phenomenon cannot be catered for by studying 'normal' controls. For example people admitted with heart failure though having a high mortality and high likelihood of readmission over the next 6 months tend to spontaneously improve whatever one does. Thus on average most will be somewhat better in a few hours however inactive the treatment. Studying normal controls can tell you nothing of this.

Third, even if one could understand the placebo effect completely it clearly varies from person to person, thus precisely negating its effects in each individual would be impossible. Counter-active therapies (even if this were possible) would actually simply induce more errors into the trial.

Finally even apparently objective measures have inherent inaccuracies - e.g. 11% variation between hemoglobin measured in the same sample using the same machinery and personnel.

In summary the current structure of placebo controlled randomised trials is designed to cater for many known and unknown potential sources of bias, including individual variation in response to therapies, variable causes of symptom complexes, variable disease stage and natural history - attempts made in advance to 'homogenise' these, to be sure, but in the certain knowledge that this can be achieved only partially. The placebo aspect is but one, and will remain incompletely understood for a long time to come.

Pebble

8th March 2009, 03:40 PM

Dear Pebble (Alan?)

Nope, try again

years osteopaths , in UK at least , were , as far as I know the only ones doing any sort of serious, educated hands on manipulation.

In more recent years physios have started doing some, following the teachings of Maitland, who, I understand, got his technqiues from watching osteopaths work (I think its called plagiarism).

Obviously physiotherapists have a different view of their history:

http://thephysiosite.com/

In Ancient Greece circa 460 BC, Hector practiced a physiotherapy technique called "hydrotherapy" - which is Greek for water treatment. Physiotherapists today still employ hydrotherapy, now evolved and adapted specifically to various patient conditions.

In 1894, the UK recognized physiotherapy as a specialized branch of nursing regulated by a Chartered Society. In the succeeding two decades, formal physiotherapy programs were established in other countries including New Zealand (1913) and the USA (1914).

The first record of American physiotherapy was at Walter Reed College and Hospital of Portland, Oregon where nurses with physical education experience worked as "reconstruction aides". These "reconstruction aides" contributed vitally to the recovery and rehabilitation of many WWI vets.

doctors too manipulation was popularised by Dr James Cyriax who used very forceful manipluations to "Replace discal fragments". They are still there in the form of BIMM (Used to be called BAMM)

Never heard of him, from what I can see on the web I get the impression he is a charlatan. Is this worth pursuing? Some practices deserve to be shut down, problem is they do tend toward countries with poor regulation if discredited.

Still probably would not like the osteopathy of today. We do not think that the spine is the source of all disease. Where we might disagree with some of the medical profession is that, in some patients, the musculo-skeletal system can have an influence on other body systems (the severe kypho-scoliosis you mentioned for example may have reduced rib expansion on breathing - is that WOO?)

The fact that severe kyphoscoliosis can lead to chest wall restriction and respiratory problems is not the issue. If spinal mal-alignment is to have any real meaning, then such patients should suffer intractably from all the conditions that osteopaths claim to be able to treat on this basis. While we are on the subject on nonsense claims, manipulation of the cranium in children with Down's Syndrome - really! If there is anything guaranteed to get you labeled a woo-monger allowing charlatans that abuse the desperation of vulnerable parents like these to remain members of your organisation is a prime example.

comment on my previous posts about the patient with the high blood pressure ?

170/120 is just about high enough to be symptomatic, so as an anecdote it is plausible.

Pebble

8th March 2009, 04:03 PM

Pebble

8th March 2009, 04:42 PM

Interesting chap Maitland:

http://www.imta.ch/gmaitland.htm

Geoffrey Douglas Maitland was born in Adelaide Australia in 1924. He trained as a physiotherapist from 1946 to 1949 after serving in the RAAF (Royal Australian Airforce) during the second World War.

His first job was at the Royal Adelaide Hospital and the Adelaide Children's Hospital, with a main interest in the treatment of orthopedic and neurological disorders. Later he continued working part time in the hospital and part time in his own private clinic. After a few years he became a part time private practitioner and part time clinical tutor at the School of Physiotherapy in the Southern Australian Institute of Technology, now the University of South Australia. He continuously studied and spent half a day each week in the Barr-Smith Library and the excellent Library at the Medical School of the University of Adelaide.

As a lecturer, he emphasized clinical examination and assessment. He stimulated his students to write treatment records from the very beginning, as he felt that “one needed to commit ones self to paper to analyze what one was doing”. In 1954 he started with manipulative therapy teaching sessions.

In 1961 he received an award from a special studies fund, which enabled him and his wife Anne to go overseas for a study tour. They visited osteopaths, chiropractors, medical doctors and physiotherapy colleagues whom they had heard and read about and corresponded with in the previous years. In London, Geoff had interesting lunchtime clinical sessions with James Cyriax and his staff. During this tour Geoff Maitland established a friendship with Gregory P. Grieve from the UK. They had extensive correspondence about their clinical experiences and this continued for many years.

In 1962 Geoff Maitland delivered a paper to the Physiotherapy Society of Australia entitled “The Problems of Teaching Vertebral Manipulation” in which he presented a clear differentiation between manipulation and mobilization and became a strong advocate of the use of gentle passive movement in the treatment of pain, in addition to the more forceful techniques used to increase range of motion.

The charge of plagirism seems overblown, prepared to learn from a variety of sources seems closer to the mark!

davidrodway

8th March 2009, 04:56 PM

Cyriax update:

Have found him - not a charlatan - though some of the clinics advertising use of his techniques cause concern:

http://www.bimm.org.uk/uploads/docs/Framework_response_BIMM_A4_8_page_booklet.pdf

It is unclear from this article whether the approach owes anything (other than superficial similarity) to osteopathy.

Dear Pebble

You beat me to it.

Why not a charlatan all of a sudden?

Do not know where Cyriax learned his manipulation, but a glance through his books will show you they were very vigorous _ eg nurse holding on to the supine patient as Cyriax, holding the chin leaned back with all his weight before performing a forceful neck rotation. He beleived he was "replacing fragments of disc".

Not sure how the present day BIMM members treat - i hope not so roughly. I know that they also like using sclerosants ("Prolotherapy). Dont know how much research has been done into their results.

Some doctors have also trained as osteopaths. There is the LCOM which is purely for training doctors in osteopathy. Why some choose to do that route and not the BIMM route I dont know. There are also a few osteopaths who then trained as doctors - eg Peter Gibbons, head of an osteopathic training college in Australia.
London College of Osteopathic MedicineHome (http://www.lcom.org.uk/home.htm)
About LCOM (http://www.lcom.org.uk/lcom.htm)
About osteopathy (http://www.lcom.org.uk/osteo.htm)
Clinic (http://www.lcom.org.uk/clinic.htm)
Training (http://www.lcom.org.uk/training.htm)
Links (http://www.lcom.org.uk/links.htm)
Contact us (http://www.lcom.org.uk/contacts.htm)
About the College

The London College of Osteopathic Medicine (LCOM) was founded in 1946 to provide training in osteopathic principles and methods for people who were already qualified medical doctors.

Those in training spend over 80% of that time is treating patients in the Clinic under the close supervision of tutors who are qualified osteopaths, registered with the General Osteopathic Council, most of whom are graduates of the College themselves and are therefore also medically qualified.

The College is recognised by the General Osteopathic Council and so its graduates are eligible to be fully registered osteopaths.

davidrodway

8th March 2009, 05:05 PM

All of which fits in nicely with what Rose Shapiro writes on p.130 of her book, Suckers: Why alternative medicine makes fools of us all:

I didnt say it was a good thing - i was pointing out the problems of getting some people off the GOsC register

That’s still not very reassuring considering the following:

Adverse effects of spinal manipulation: a systematic review

I thoiught I had made the point that if there were anything in the history that contra-indicated cervical LAHVT , then an LAHVT is not performed. The value of pre screening is , as pointed out, not proved, but if i hear a carotid bruit or for example see silver wiring or vessel tortuosity with an opthalmoscope the i am NOT going to LAHVT whatever the research says

He’s probably erring on the side of caution since it's apparent that some osteopaths are deluded enough to use quackery such as craniosacral therapy/cranial osteopathy on their patients.

Maybe, may be not.

One has to assume that Ernst is very familiar with what you do when you consider that he was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty,
and that he has also been trained in spinal manipulation and has applied it clinically.

I thought it just said trained in acupuncture and homeopathy. I dont know that Austrianosteopaths do what we do in Britain anyway. Assume nothing.

]It’s not up to Ernst to do the research; rather it is the responsibility of the proponents who make the claims. Ernst’s job is to evaluate the emerging evidence for CAM from a scientific point of view. What could be fairer than that?

Good point, but i still think he could get more aquainted with what osteopaths actually do.

BTW, re the cost-effectiveness of osteopathy. The following review from 2006 might be of interest to you,

Will look up these references. I beleive there is some interesting news on cost effectiveness coming out in May 2009.

Pebble

8th March 2009, 05:22 PM

Why not a charlatan all of a sudden?

Holding that manipulative and physical therapies have a role in neuromuscular conditions is hardly off beam. Would need more in-depth study to determine if there were aspects of what he believed that were inconsistent with the prevailing level of knowledge at the time, but from the paper found all seems within the realms of plausibility given the limited understanding of the time.

Some doctors are skeptics, and use techniques learned through scepticism in their daily practice - does that legitimise skepticism?

davidrodway

8th March 2009, 05:25 PM

DearPebble

The charge of plagirism seems overblown, prepared to learn from a variety of sources seems closer to the mark![/quote]

It would be interesting to know what he drew from which sources, what he left out and why. And how much did he learn. Osteopathy even then was a four year course, and I assume the other course swere rigorous. I dont think a few weeks studying physiotherapy would equip me to launch a school of Rodway Manipulation.

i understand Maitland manipulation is graded 1 to 4, 1 being gentle, 4 being what we would call an LAHVT (although we do it better of course;)). My problem with this is that
1 it impies an LAHVT has to be forceful
2 It implies that Grade 4 is a difference of quantity, wheras I would say that it is a fundmantally different manipulation from grades 1 to 3 (those grades are also called mobilsation by physos and articulation by osteopaths)

Most hands on i UK is done by osteopaths. When I trained I was interested in the biomechanics of the body and hands-on ttt - that is why I chose osteopathy (i had , perhaps luckily, never heard of chiropractors.)Apart from obvious "tribal" reasons it doesnt really bother me if we eventually have an amalgamation of the best of osteopathy, hands on physio, orthopaedic medicine and even chiro. Perhaps thats the way its going. We'll end up with a profession of primary care practitioners with good knowledge, diagnostic skill and the range of manipulative skills in their therapeutic toolbox. Only thing is, we have already got them - they are called osteopaths

davidrodway

8th March 2009, 05:29 PM

Pebble wrote:

Some more on the woo origins of osteopathy from Rose Shapiro on p.134 of her book:

I have already commented on that. WOO origins maybe, but we are in 2009 now not 1875

]

davidrodway

8th March 2009, 05:43 PM

Holding that manipulative and physical therapies have a role in neuromuscular conditions is hardly off beam. Would need more in-depth study to determine if there were aspects of what he believed that were inconsistent with the prevailing level of knowledge at the time, but from the paper found all seems within the realms of plausibility given the limited understanding of the time.

Some doctors are skeptics, and use techniques learned through scepticism in their daily practice - does that legitimise skepticism?

Given that I trained in the 1970s, I can tell you that yes his ideas were inconsistent with knowledge. Or, put it another way, his claims of replacing discal fragments were derided by the osteopathic profession.

We were also by the way, advising against bed rest, the routine use of x-rays and the use of baby strollers. The "proper doctors" have now comme round to our position (no thanks to us). In fact, they have gone completely the other way.

"Consistent with the kowledge of the time (Or lack of it)" - my point about A T Stills ideas, I think

Your first sentence - very telling. Those ideas were considered "off beam" then .Its perhaps a measure of how far we have come that you think that manipulation has a role to play in neuromuscular conditions. Back in the 1960s and 70s even that was not accepted. Cyriax had almost as much struggle with his medical colleagues as osteopaths did.

Holding that manipulative and physical therapies have a role in neuromuscular conditions is hardly off beam. That sounds to me perilously close to an osteopathic viewpoint. Careful!

Sorry, do not understand your last sentence.Please explain

davidrodway

8th March 2009, 05:50 PM

Shapiro
Osteopathy and chiropractic may be popular with patients the world over, but make enquiries beyond reports of customer satisfaction and there is minimal evidence to show that spinal manipulation is any better at alleviating back pain than gentle exercise. In a review of current research that enraged osteopaths and chiropractors, leading sceptic Professor Edzard Ernst concluded that there was no evidence to suggest that spinal manipulation was an effective intervention for any condition. This finding applies to both osteopathy and chiropractic

As far as I can recall from my brief reading of Ernst s book, the small part on osteopathy, this is not what he says at all.

I have previously pointed out errors in this authors work re osteopathic education . I am not impressed.

davidrodway

8th March 2009, 05:57 PM

[Shapiro
Osteopathy and chiropractic may be popular with patients the world over, but make enquiries beyond reports of customer satisfaction and there is minimal evidence to show that spinal manipulation is any better at alleviating back pain than gentle exercise. In a review of current research that enraged osteopaths and chiropractors, leading sceptic Professor Edzard Ernst concluded that there was no evidence to suggest that spinal manipulation was an effective intervention for any condition. This finding applies to both osteopathy and chiropractic

Here is what he really said . Still trust that Shapiro or are we starting to get a little skeptical here ? (my italics below)

WHAT IS IT?
A manual therapy which focuses on the musculoskeletal system to treat disease. Osteopaths use a range of techniques to mobilise soft tissues, bones and joints. Osteopathy and chiropractic therapy have much in common, but there are also important differences.

Osteopaths tend to use gentler techniques and often employ massage-like treatments. They also place less emphasis on the spine than chiropractors, and they rarely move the vertebral joints beyond their physical range of motion, unlike chiropractors. Therefore osteopathic interventions are less likely to injure.

In general they treat mainly musculoskeletal problems, but many also claim to treat other conditions such as asthma, ear infection and colic.

DOES IT WORK?
There is reasonably good evidence that the osteopathic approach is as effective as conventional treatments for back pain (if, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercises, which is backed by similar evidence and which is more cost- effective as it is often done in groups).

There is no good evidence to support the use of osteopathy in non-musculoskeletal conditions.

People with severe osteoporosis, bone cancer, infections of the bone or bleeding problems should confirm with the osteopath that they will not receive forceful manual treatments.

davidrodway

8th March 2009, 06:15 PM

For the record, here are some relevant Cochrane report summaries.

Neck pain
Multimodal care has short-term and long-term maintained benefits for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. The evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings.

Non-invasive physical treatments for chronic/recurrent headaches
Various physical treatments are often used instead of, or in addition to, medications to treat headaches. Evidence from controlled trials suggests that several non-invasive physical treatments may help prevent chronic/recurrent headaches. Spinal manipulation may be effective for migraine and chronic tension-type headache. Both spinal manipulation and neck exercises may be effective for cervicogenic headache. Weaker evidence suggests that other treatments may also be effective: pulsating electromagnetic fields and transcutaneous electrical nerve stimulation (TENS) for migraine, and therapeutic touch, cranial electrotherapy, TENS, and a combination of self-massage/TENS/stretching for tension-type headache. Although none of these treatments has conclusive evidence for effectiveness, all appear to be associated with little risk of serious adverse effects.

Asthma

Various manual forms of therapy are used to try and relieve asthma. Chiropractic and osteopathic techniques aim to increase movement in the rib cage and the spine to try and improve the working of the lungs and circulation. Other manual techniques include chest tapping, shaking, vibration, and postures to help shift and cough up phlegm. Massage is also used. Various therapists use these techniques, including chiropractors, physiotherapists, osteopaths and respiratory therapists. The review found there is not enough evidence from trials to show whether any of these therapies can improve asthma symptoms, and more research is needed.

LBP
Low-back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. Seventy to 85% of the population will experience LBP at some time in their lives. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function.
Massage in this review is defined as soft-tissue manipulation using hands or a mechanical device on any body part. Non-specific LBP indicates that no specific cause is detectable, such as infection, neoplasm, metastasis, osteoporosis, rheumatoid arthritis, fracture, inflammatory process or radicular syndrome (pain, tingling or numbnness spreading down the leg.
Thirteen randomized trials (1596 participants) assessing various types of massage therapy for low-back pain were included in this review. Eight had a high risk and five had a low risk of bias. Massage was more likely to work when combined with exercises (usually stretching) and education. The amount of benefit was more than that achieved by joint mobilization, relaxation, physical therapy, self-care education or acupuncture. It seems that acupressure or pressure point massage techniques provide more relief than classic (Swedish) massage, although more research is needed to confirm this.
No serious adverse events were reported by any patient in the included studies. However, some patients reported soreness during or shortly after the treatment. Some patients also reported an allergic reaction (e.g. rash or pimples) to the massage oil.
In summary, massage might be beneficial for patients with subacute (lasting four to 12 weeks) and chronic (lasting longer than 12 weeks) non-specific low-back pain, especially when combined with exercises and education.

Pebble

8th March 2009, 07:00 PM

Your first sentence - very telling. Those ideas were considered "off beam" then .Its perhaps a measure of how far we have come that you think that manipulation has a role to play in neuromuscular conditions. Back in the 1960s and 70s even that was not accepted. Cyriax had almost as much struggle with his medical colleagues as osteopaths did.

Holding that manipulative and physical therapies have a role in neuromuscular conditions is hardly off beam. That sounds to me perilously close to an osteopathic viewpoint. Careful!

Sorry, do not understand your last sentence.Please explain

The point is that medicine and science should not be afraid to evolve, new ideas may come from anywhere, often quite barking. If the evidence is supportive then further evidence gathering follows. Thus it is true that many ideas with regard to manipulation were learnt from chriopracters, that is not the same as adopting or even legitimising chiropracty. Again some of the pioneers had incorrect understanding of how their approach might work, again so long as they research and adapt according to the findings that is fine.

Where one maintains that one particular approach is correct and that despite substantial evidence one promotes this approach over other proven techniques a real problem exists. In the setting of asthma which kills people, and where there is good evidence of efficacy (even if with associated problems) of the conventional approach, then anyone who advocates osteopathy except in the setting of robust clinical trials is beyond the pale.

Of note further on you quote the Cochrane abstracts, very little support there even in conditions where osteopathy might be expected to work!

sunzi1.lib.hku.hk/hkjo/view/25/2500006.pdf

During the 19th century, the medical profession began to look at manipulation as a means of curing back-
ache and other discomforts of the spine and limbs .
Oscillatory tecniques were first recommended by Recamier in 1838 for treatment of Torticollis . Manual
vibration was intensively employed by Kellgreen, a Swedish physiotherapist working in London at the turn
of the century . These techniques have been adopted and improved on by modern therapists such as
Maitland and Grieves .
Since the turn of the century, there have been many men who have put respectability into the fine art of
manipulation . John Mennell practised in London as did Drs . Edgar and James Cyriax, father and son, and
Dr . Main in France, to name a few.

As for the last sentence, referring to your eulogising about the existence of doctors who train in osteopathy.

FInally I note you have not commented on cranial osteopathy and Down's Syndrome.

Blue Wode

8th March 2009, 07:03 PM

David Rodway wrote:

I beleive there is some interesting news on cost effectiveness coming out in May 2009.
It wouldn’t happen to be the new NICE clinical guidelines on low back pain? If so, I see that there’s an acupuncturist and a chiropractor (as well as an osteopath - Steven Vogel) serving on the Guideline Development Group (GDG):
http://www.nice.org.uk/nicemedia/pdf/LowBackPainGDGMembersList270407.pdf (http://www.nice.org.uk/nicemedia/pdf/LowBackPainGDGMembersList270407.pdf)

BTW, it’s worth noting that the chiropractic representative is the Chairman of the General Chiropractic Council (GCC) who is described as having “experience and working knowledge of non specific low back pain”. An interesting example of his work in his capacity of Chairman of the GCC can be found here:
http://www.gcc-uk.org/files/link_file/DAILY%20MAIL%2012%20December%202006.pdf (http://www.gcc-uk.org/files/link_file/DAILY%20MAIL%2012%20December%202006.pdf)

You really have to wonder how a man who recently insisted that “there’s no available evidence to show that manipulation of the neck by chiropractors has ever caused a stroke” can be a trusted member of a clinical ‘excellence’ team. To learn more about Peter Dixon and his (lack of) qualifications, scroll down this link until you come to ‘Edzard Ernst again challenges chiropractors in UK’:
http://www.healthwatcher.net/chirowatch.com/cw-cervical.html (http://www.healthwatcher.net/chirowatch.com/cw-cervical.html)

David Rodway wrote:

Shapiro
Osteopathy and chiropractic may be popular with patients the world over, but make enquiries beyond reports of customer satisfaction and there is minimal evidence to show that spinal manipulation is any better at alleviating back pain than gentle exercise. In a review of current research that enraged osteopaths and chiropractors, leading sceptic Professor Edzard Ernst concluded that there was no evidence to suggest that spinal manipulation was an effective intervention for any condition. This finding applies to both osteopathy and chiropractic

Here is what he [Ernst] really said . Still trust that Shapiro or are we starting to get a little skeptical here ? (my italics below)

WHAT IS IT?
A manual therapy which focuses on the musculoskeletal system to treat disease. Osteopaths use a range of techniques to mobilise soft tissues, bones and joints. Osteopathy and chiropractic therapy have much in common, but there are also important differences.

Osteopaths tend to use gentler techniques and often employ massage-like treatments. They also place less emphasis on the spine than chiropractors, and they rarely move the vertebral joints beyond their physical range of motion, unlike chiropractors. Therefore osteopathic interventions are less likely to injure.

In general they treat mainly musculoskeletal problems, but many also claim to treat other conditions such as asthma, ear infection and colic.

DOES IT WORK?
There is reasonably good evidence that the osteopathic approach is as effective as conventional treatments for back pain (if, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercises, which is backed by similar evidence and which is more cost- effective as it is often done in groups).

There is no good evidence to support the use of osteopathy in non-musculoskeletal conditions.

People with severe osteoporosis, bone cancer, infections of the bone or bleeding problems should confirm with the osteopath that they will not receive forceful manual treatments.

When her book was first published in January 2008, Rose Shapiro was correct in saying that Professor Edzard Ernst had concluded that there was no evidence to suggest that spinal manipulation was an effective intervention for any condition. This was her source:

A systematic review of systematic reviews of spinal manipulation (2006)

Conclusions: Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.

http://jrsm.rsmjournals.com/cgi/content/full/99/4/192 (http://jrsm.rsmjournals.com/cgi/content/full/99/4/192)

Singh and Ernst’s book, Trick or Treatment? Alternative Medicine on Trial, was published in April 2008, and it did not make any reference to spinal manipulation in the section on Osteopathy. Just for the record, here, in its entirety, is what the page (321) says:

Osteopathy

A manual therapy involving a range of techniques, particularly mobilization of soft tissues, bones and joints. Osteopaths focus on the musculoskeletal system in treating health and disease.

Background
The American Andrew Taylor Still founded osteopathy in 1874 – around the time when chiropractic therapy (see Chapter 4) was created by D. D. Palmer. Osteopathy and chiropractic therapy have much in common, but there are also important differences. Osteopaths tend to use gentler techniques and often employ massage-like treatments. They also place less emphasis on the spine than chiropractors, and they rarely move the vertebral joints beyond their physical range of motion as chiropractors tend to do. Therefore osteopathic interventions are burdened with less risk of injury.

In the US, doctors of osteopathy (DOs) are entirely mainstream and only rarely practise manual therapies. In the UK, osteopaths are regulated by statute but considered to be complementary/alternative practitioners. British osteopaths treat mostly musculoskeletal problems, but many also claim to treat other conditions such as asthma, ear infection and colic.

What is the evidence?
There is reasonably good evidence that the osteopathic approach of mobilization is as effective (or ineffective) as conventional treatments for back pain. For all other indications, the data are not conclusive. In particular, the overall conclusion from several clinical trials is that there is no good evidence to support the use of osteopathy in non-musculoskeletal conditions.

Because their techniques are generally much gentler than those of chiropractors, osteopaths cause adverse effects much less frequently. Nevertheless, people with severe osteoporosis, bone cancer, infections of the bone or bleeding problems should confirm with the osteopath that they will not receive forceful manual treatments.

Conclusion.
The evidence that the osteopathic approach is effective for treating back pain is reasonably sound. If, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercise, which is backed by similar evidence and which can be done in groups and therefore is more cost-effective. There is no evidence to support osteopathy for the treatment of non-musculoskeletal conditions.

It does appear to be true that osteopaths cause less adverse effects related to the cervical spine when compared to chiropractors. See fig.2 here:
http://www.ptjournal.org/cgi/content/full/79/1/50 (http://www.ptjournal.org/cgi/content/full/79/1/50)

davidrodway

8th March 2009, 07:25 PM

BTW, it’s worth noting that the chiropractic representative is the Chairman of the General Chiropractic Council (GCC) who is described as having “experience and working knowledge of non specific low back pain”. An interesting example of his work in his capacity of Chairman of the GCC can be found here:
You really have to wonder how a man who recently insisted that “there’s no available evidence to show that manipulation of the neck by chiropractors has ever caused a stroke” can be a trusted member of a clinical ‘excellence’ team. To learn more about Peter Dixon and his (lack of) qualifications, scroll down this link until you come to ‘Edzard Ernst again challenges chiropractors in UK’:

Im not defending chiropractors!
(http://www.healthwatcher.net/chirowatch.com/cw-cervical.html)

Singh and Ernst’s book, Trick or Treatment? Alternative Medicine on Trial, was published in April 2008, and it did not make any reference to spinal manipulation in the section on Osteopathy. Just for the record, here, in its entirety, is what the page (321) says:

Osteopathic hands on treatment of the spine is spinal manipulation! ( not just LAHVT, but MET, soft tissue, articulation etc,

davidrodway

8th March 2009, 07:51 PM

The point is that medicine and science should not be afraid to evolve, new ideas may come from anywhere, often quite barking. If the evidence is supportive then further evidence gathering follows. Thus it is true that many ideas with regard to manipulation were learnt from chriopracters, that is not the same as adopting or even legitimising chiropracty. Again some of the pioneers had incorrect understanding of how their approach might work, again so long as they research and adapt according to the findings that is fine.

I am not a chiropractor, I am an osteopath, You could substitute the word Osteopathy for the word Medicine in your first sentence. By Pioneers do you mean the Pioneers of osteopathy? :smiley:

Where one maintains that one particular approach is correct and that despite substantial evidence one promotes this approach over other proven techniques a real problem exists. In the setting of asthma which kills people, and where there is good evidence of efficacy (even if with associated problems) of the conventional approach, then anyone who advocates osteopathy except in the setting of robust clinical trials is beyond the pale.

I know of no case where an osteopath has advised an asthma patient to give up their medication

Of note further on you quote the Cochrane abstracts, very little support there even in conditions where osteopathy might be expected to work!

Well I think it a good idea to have the evidence out in the open whichever position it favours, dont you? And there is some evidence. My reading of it is that on some of the conditions physical ttt/ manipulation is as effective as "Conventional" ttt

THe histroy you quote missed out a few, including Alan Stoddard, osteopath and doctor, recently deceased i beleive. Author of two quite good books on osteopathy.

As for the last sentence, referring to your eulogising about the existence of doctors who train in osteopathy.

Was not aware I was eulogising

FInally I note you have not commented on cranial osteopathy and Down's Syndrome.

Apologies . Thought I had, but looking back seems it didnt get on there. So - if you go on the cranial site there is an article by N Handoll about cranial ttt of Downs children. It's rubbish. He talks about ttt by improving their breathing. The breathing improves anyway as they grow ( cross sectional area increases at a rate that is the square of the length or however it goes).

Perhaps i sholud crtique his article in a journal

He has also written a book called the Anatomy of Potency (no, it is not a pop-up book) which , as gfar as i can be bothered to make out, claims that somehow he is channeling the cosmic background radiation into his patients. And you think manipulation for back pain is WOO!

Apparently unless he has an affaoir with a patient or they dont like his wallpaper the GOsC cannot or will not intervene. But there is now a new GOsC council and a revalidation coming up.

Blue Wode

8th March 2009, 07:54 PM

David Rodway wrote:

Im not defending chiropractors!
I know you’re not, but I thought I’d slip in that information for the benefit of readers who may not know how deceptive chiropractors can be. ;)

David Rodway wrote:

Osteopathic hands on treatment of the spine is spinal manipulation! ( not just LAHVT, but MET, soft tissue, articulation etc,
Singh and Ernst don’t make that clear, however they do say that osteopaths “place less emphasis on the spine” - something which they seem to view as being more favourable than chiropractic therapy.

JJM

8th March 2009, 08:17 PM

{snip} The fact that severe kyphoscoliosis can lead to chest wall restriction and respiratory problems is not the issue. If spinal mal-alignment is to have any real meaning, then such patients should suffer intractably from all the conditions that osteopaths claim to be able to treat on this basis. {snip}Osteopaths in the UK are, literally, foreign to me. Your example of kyphoscoliosis (while I know what it means) is a new argument in my experience. In particular, it reminds me that transplanted organs work well without nerve-connections to the spine. Also, internal organs (not under voluntary-nerve control) work after spine injury.

Mojo

8th March 2009, 08:30 PM

Pebble

8th March 2009, 09:19 PM

Apologies . Thought I had, but looking back seems it didnt get on there. So - if you go on the cranial site there is an article by N Handoll about cranial ttt of Downs children. It's rubbish. He talks about ttt by improving their breathing. The breathing improves anyway as they grow ( cross sectional area increases at a rate that is the square of the length or however it goes).

Perhaps i sholud crtique his article in a journal

He has also written a book called the Anatomy of Potency (no, it is not a pop-up book) which , as gfar as i can be bothered to make out, claims that somehow he is channeling the cosmic background radiation into his patients. And you think manipulation for back pain is WOO!

Apparently unless he has an affaoir with a patient or they dont like his wallpaper the GOsC cannot or will not intervene. But there is now a new GOsC council and a revalidation coming up.

Thanks for this, now that your position on at least this aspect of cranial osteopathy has been clarified, I feel much more comfortable with the remainder of your contentions.

I think it is essential to be absolutely clear that there are aspects of any profession that need to be absolutely rejected. I would as you have noted put all of cranial therapies in this band. I have no objection to osteopathy for musculoskeletal conditions, even if the evidence base seems too light to recommend it above other therapies. I have major reservations in respect of non musculoskeletal conditions, but am happy to look at the evidence. However, simply not advising people to stop effective therapies is not enough. When using unproven therapies, this should be in the setting of some form of clinical trial (not always a full blown DBRCT - even registries have their place).

davidrodway

8th March 2009, 09:26 PM

It's a little unfair to expect Shapiro to have known what an article that had not yet been published was going to say, isn't it? She actually referred to a Paper by Ernst and Canter which concluded precisely what she said it did. If you had bothered to look up the reference given directly following the words you quoted you would have known this - it's freely available (http://jrsm.rsmjournals.com/cgi/content/full/99/4/192) on the internet.

Mea culpa I did not check when she wrote the article .Presume now that Ernst and Singh seem (Am i right?) here to put osteopathy in a more favourable light in Trick or Trerament that she will be revIsing her opinion in future writings?

Her view on osteopathic education in Britain is completely wrong tho.

davidrodway

8th March 2009, 09:37 PM

Thanks for this, now that your position on at least this aspect of cranial osteopathy has been clarified, I feel much more comfortable with the remainder of your contentions.

I think it is essential to be absolutely clear that there are aspects of any profession that need to be absolutely rejected. I would as you have noted put all of cranial therapies in this band. I have no objection to osteopathy for musculoskeletal conditions, even if the evidence base seems too light to recommend it above other therapies. I have major reservations in respect of non musculoskeletal conditions, but am happy to look at the evidence. However, simply not advising people to stop effective therapies is not enough. When using unproven therapies, this should be in the setting of some form of clinical trial (not always a full blown DBRCT - even registries have their place).

I sometimes think that it would be best if there was a split into two professions - osteopaths and cranial osteopaths. Having said that i do have a high regard for some very cranial osteopaths - theres one in London whose name escapes me who went on to train as a dentist just to get more understanding of the cranial anatomy Martin Pascoe, thats it.

Re asthma - you agreed that a kypho-scoliosis can affect rib expansion. Is it such a big step to think that poor rib or dorsal spine mobility might exaccerbate asthma? Of course this possibility does not then automatically mean that osteopathgic ttt helps asthmatics, but its surely plausible and worth investigating?

I think on the reply re Downs that I failed to upload I also asked what you meant exactly by spinal mis or mal alignment. Sounds a bit like chiropractic subluxation (in which osteopaths do NOT beleive) Or do you mean scoliosis or spondylo/ retro listhesis?

davidrodway

8th March 2009, 09:45 PM

David Rodway wrote:

I know you’re not, but I thought I’d slip in that information for the benefit of readers who may not know how deceptive chiropractors can be. ;)

David Rodway wrote:

Singh and Ernst don’t make that clear, however they do say that osteopaths “place less emphasis on the spine” - something which they seem to view as being more favourable than chiropractic therapy.

Well , we dont think that all disease comes from pressure on spinal nerves, and we treat the limbs as well.

Other differences with chiros - we do not beleive in spinal subluxations, we do use LAHVT but not on everyone and we use a lot of other manual treatrments, we do not see pts so frequently or so many weeks, we do not routinely advise regular maintainance ttt, and we are not good businessmen. An osteopath was also recently hauled up in front of the GOsC for saying that osteopaths had bigger penises (I expect the BCA will sue him as well)!

JJM

8th March 2009, 10:01 PM

Mr. Rodway, I await your evidence for the effectiveness of your treatment for sinusitis.

Pebble

8th March 2009, 11:05 PM

While we are on the subject on nonsense claims, manipulation of the cranium in children with Down's Syndrome - really! If there is anything guaranteed to get you labeled a woo-monger allowing charlatans that abuse the desperation of vulnerable parents like these to remain members of your organisation is a prime example.

Dear David,

Nothing here about the spine - aligned or otherwise. This is simply abuse, using vulnerable rather suggestible parents to make some money while putting disabled babies and small children through useless treatments to which they themselves cannot consent.

Manipulating the cranium for colic etc is just plain nonsense, no ifs or buts there.

In respect of asthma, I do not contend that it is completely understood, in particular the innervation of the bronchial airways, their reaction to histiocyte degranulation and other stimuli etc. However, stretching this to manipulation of chest wall muscles (accepting some rather poor quality evidence for physiotherapy for sputum dislodgement) - is not plausible. So in such areas I am quite open to well structured research, not fee paying 'treatment' without rigorous registry or comparative trials and commitment to publish findings.

davidrodway

8th March 2009, 11:32 PM

Mr. Rodway, I await your evidence for the effectiveness of your treatment for sinusitis.

Dear Mr JJM (why so formal?)

Sorry for te delay. Been a bit busy
Try
Do osteopathic treatments improve the symptoms of headache and/or sinus pressure in patients with chronic rhino sinusitis (CRS)? A randomized controlled trial

International Journal of Osteopathic Medicine, Volume 11, Issue 4, December 2008, Page 157
U. Steinbauer, S. Roos, P. Amann, F. Schwerla and K.L. Resch

Yours in haste

David

davidrodway

8th March 2009, 11:37 PM

[quote=Pebble;56925]Dear David,

Nothing here about the spine - aligned or otherwise. This is simply abuse, using vulnerable rather suggestible parents to make some money while putting disabled babies and small children through useless treatments to which they themselves cannot consent.

Dear Pebble
Sorry, some genuine confusion here. I thought i was replying to something you said earlier about spinal mal alignment or misalignment. Perhaps it wasnt you.

davidrodway

8th March 2009, 11:53 PM

Mojo

9th March 2009, 12:04 AM

Sorry for te delay. Been a bit busy
Try
Do osteopathic treatments improve the symptoms of headache and/or sinus pressure in patients with chronic rhino sinusitis (CRS)? A randomized controlled trial

International Journal of Osteopathic Medicine, Volume 11, Issue 4, December 2008, Page 157
U. Steinbauer, S. Roos, P. Amann, F. Schwerla and K.L. Resch
Doesn't appear to be an abstract freely available, much less full text (and doesn't seem to be indexed on pubmed). Is it the same study as this (http://www.osteopathic-research.com/cgi-bin/afo/Search1.pl?show_one=30903), which has the same title and three of the same authors, but seems to have been published a couple of years earlier?

JJM

9th March 2009, 09:08 PM

davidrodway

9th March 2009, 09:12 PM

Doesn't appear to be an abstract freely available, much less full text (and doesn't seem to be indexed on pubmed). Is it the same study as this (http://www.osteopathic-research.com/cgi-bin/afo/Search1.pl?show_one=30903), which has the same title and three of the same authors, but seems to have been published a couple of years earlier?

It might be, not sure. I shoul have the IJOM backcopies somewhere, so will try to look it up and let you know.
However the sun is now shining and my wife informs me that I have used up two months Computer Playtime in one day, so it may be a while before I can revisi you chums.

Meanwhile, I commend the column in Mondays Daily Telegraoh by I tknk Kirstin somebody , an osteopath (towads the back, near James Le Fanu.)I dont agree with all he says but he seems a fairly sensible sort for an osteopath and if you want to know (probably dont) how osteopaths work, it gives a good flavour of present day practice.

Hope my posts have given food for thought. Be sceptical of everything, I say, and don't trust it just because it is "Orthodox" (medicine or anything).

Remember -
"Either it is true that a medicine works or it isn't.
It cannot be false in the ordinary sense but true in some 'alternative' sense."
(R Dawkins)

And a final thought on chiropractors -

So the British Chiropractic Association is suing Mr Simon Singh for his article in the Guardian suggesting that chiropractic claims to help babies with colic are bogus. Rather than present their evidence, the chiropractors have chosen to use their financial muscle to gag him, no doubt advancing for all humanity the practice of health care.

Coincidentally we also have some poor osteopath dragged before the Grand Inquisition of the GOsC accused of joking that the difference between osteopaths and chiropractors is the length and/or breadth (I hope, for the sake of the legal niceties it is made clear just which dimensions are involved ) of their penises.

Even should he escape the GOsC, it appears then that he might then face the wrath of the BCA, who on this performance would seem happy to sue him, on behalf of their members ( no pun intended) for slander.

With that in mind it seems remise of the GOsC not, in the recent questionnaire in support of Diversity and Dullness to have added to the questions one concerning phallic size, in case such information were needed at the inevitable court case. After all, the chiropractors are no doubt at this moment aquiring such vital information from their profession,

It could be added to the questions on race (“human”) and sexuality (”black lesbian trapped in a white man’s body)

Smith

13th March 2009, 11:30 AM

Well, there has been some pretty lax scepticism in this thread, with some people rejecting ideas apparently without having subjected them to any kind of scrutiny at all, and others quite ready to criticise practices when obviously possessing little or no knowledge of their theoretical basis.

But the main thrust of the more serious criticism seems to be the objection that osteopathic practice is not evidence-based, with the implication therein that all medicine SHOULD be "evidence based medicine" (as per the accepted modern use of that appellative).

Can none of the self-proclaimed sKKKeptics out there see anything wrong with this?

If not, I'm amazed.

filippo lippi

13th March 2009, 12:35 PM

sKKKeptics

Way to make friends

skbuncks

13th March 2009, 12:48 PM

snip...But the main thrust of the more serious criticism seems to be the objection that osteopathic practice is not evidence-based, with the implication therein that all medicine SHOULD be "evidence based medicine" (as per the accepted modern use of that appellative).

Can none of the self-proclaimed sKKKeptics out there see anything wrong with this?

If not, I'm amazed.

No. I like evidence that a treatment is going to work.

Now, I have here £1Million locked in a Nigerain Trust Fund. For legal reasons I cant get to it right now, but if you send me £10000 I can obtain legal representation and release the cash and give you half for your assistance

What? You want evidence that the money exists? Nah, Just trust me

skb

Pebble

13th March 2009, 02:09 PM

But the main thrust of the more serious criticism seems to be the objection that osteopathic practice is not evidence-based, with the implication therein that all medicine SHOULD be "evidence based medicine" (as per the accepted modern use of that appellative).

Skeptics looking for evidence, whatever next?

Croydon Bob

13th March 2009, 02:39 PM

Can none of the self-proclaimed sKKKeptics out there see anything wrong with this? I've never heard of a 'skkkeptic' before, it seems to be a name that a few pathetic loonies have used to label people who are smarter than them. But as a 'self-proclaimed' skeptic, I see nothing wrong with the desire that all medicine should be evidence based medicine. Please explain what you mean oh great wise loony.

Smith

13th March 2009, 05:27 PM

OK, here are some thoughts:

1) Is it not equally wrong to judge everything skeptically by equal and extreme measure, as to accept anything and everything without scrutiny? I would suggest that there may be a healthy degree of skepticism, as well as degrees which are inappropriate by their lack or by their excess, according to the sphere application. There are whole spheres of human activity and endeavour where it may be inappropriate, impractical, even deleterious to limit our actions to those validated by a formal evidence base. I would suggest that healthcare may be one of these.

2) Is there any reason to believe, and I suppose that here the only good reason would be hard evidence, that evidence-limited medicine provides higher quality care? Or increased patient satisfaction? Or objectively improved outcomes?

3) Most osteopaths in Europe work in private settings. Most patients presenting to the clinic are referrals from other patients. They go to see the osteopath because a relative or friend that they trust has told them that osteopathy helped them, and this to that person is "evidence". The skeptic might not value that kind of evidence but many people apparently do, as osteopathy is increasingly popular.

Honestly, I'd never considered myself a lunatic before, but Croydon Bob, you have opened my eyes. No need to be rude about it, though.

Trinoc

13th March 2009, 06:04 PM

No need to be rude about it, though.
Calling us sKKKeptics was not exactly a good way to encourage us to take your views seriously.

As it happens, I can agree with some of what you say, but if you are as prejudiced against skeptics as you suggest we are against your views then it's not a very good basis for a debate.

Smith

13th March 2009, 06:17 PM

Calling us sKKKeptics was not exactly a good way to encourage us to take your views seriously.

As it happens, I can agree with some of what you say, but if you are as prejudiced against skeptics as you suggest we are against your views then it's not a very good basis for a debate.

Point taken about the name distortion - sorry.

I am not prejudiced against skeptics, I am probably more than averagely skeptical myself. But I thought there was perhaps a lack of balance.

Pebble

13th March 2009, 06:20 PM

2) Is there any reason to believe, and I suppose that here the only good reason would be hard evidence, that evidence-limited medicine provides higher quality care? Or increased patient satisfaction? Or objectively improved outcomes?

Yes actually.

Take for example heart failure. Treatments valued by practicioners and patients in the 1950's and 1960's were shown by the Framingham heart study and other registeries not to have improved prognosis at all. The evidence was that they appeared to make patients feel better. The deomonstration of efficacy of ACE inhibitors, Betablockers, Digoxin, Spironolactone, biventricular pacing and implantable cardioverter defibrillator therapies has revolutionised the quality of life, and longevity of heart failure patients by any measure you care to use.

The same can be shown for many areas e.g. thrombolysis and primary angioplasty for myocardial infarction; pacing for heart block; cardiac surgery for valvular heart disease or severe coronary disease; advanced therapies for pulmonary arterial hypertension; much of the cancer work etc. etc.

The skeptic might not value that kind of evidence but many people apparently do, as osteopathy is increasingly popular.

Popularity is a measure of popularity not efficacy. So people like fast cars, doesn't make them good for the enviornment or consequently the longterm quality of life of the owners.

People like many things that are not nessarily good for them, cigarettes, alcohol, recreational drugs, the sales pitches from con artists.

Where there are proven effective therapies, the minimum standard should be equivalent efficacy.

Where disbaled children are being abused by the collusion of charlatans (or deluded individuals) and desperate parents, greater safeguards should be in place.

JJM

14th March 2009, 07:21 AM

{snip} There are whole spheres of human activity and endeavour where it may be inappropriate, impractical, even deleterious to limit our actions to those validated by a formal evidence base. I would suggest that healthcare may be one of these. {snip}What you suggest is wrong. Non-science-based "medicine" favored bleeding, scalding, treppaning, emetics, purgatives etc. that did more harm than good. Medicine really started to advance only after we realized that simple, uncontrolled observation fools us.

Pebble

14th March 2009, 08:49 AM

2) Is there any reason to believe, and I suppose that here the only good reason would be hard evidence, that evidence-limited medicine provides higher quality care? Or increased patient satisfaction? Or objectively improved outcomes?

.

To address another aspect of this question - what do you do when evidence is limited? The answer is to objectively evaluate and rate the available evidence (even if that comes from anecdotes) and where the evidence is weak to agree a common approach based essentially on best guess. These are called guidelines. The trick is having identified areas of lack of evidence, to ensure that research is focused on those areas with poor quality evidence, so that the next set of guidelines on the same subject is based o higher quality evidence.

You may wonder why standardise approach if there very poor evidence. The answer lies in registeries of outcome. Anyone practicioner performs a limited number of treatments, thus cannot really see if the approach used is as good as others better, or worse. With standardisation, evidence can be accumulated from many practicioners, this allows you you assess the likely size of study you would need to prove that any alternative approach is better, for the purpose of proper studies.

A good example of this is the BTS oxygen therapy guidelines.

Smith

14th March 2009, 10:23 AM

Take for example heart failure. Treatments valued by practicioners and patients in the 1950's and 1960's were shown by the Framingham heart study and other registeries not to have improved prognosis at all. The evidence was that they appeared to make patients feel better.

That is interesting and obviously has to be taken into account.

The deomonstration of efficacy of ACE inhibitors, Betablockers, Digoxin, Spironolactone, biventricular pacing and implantable cardioverter defibrillator therapies has revolutionised the quality of life, and longevity of heart failure patients by any measure you care to use.

The same can be shown for many areas... ...much of the cancer work etc. etc..

How much of the improvement in quality of life and longevity can be attributed to lifestyle changes? What about general increases in healthcare spending rather than the type of healthcare received? What if we throw all-causes morbidity and mortality into the equation in these groups?

I would hope that the evidence based approach has not led to the reduction or abandonment of unproven and time-consuming aspects of care such nursing or bedside manner. You will notice that my objection is to evidence-limited medicine, not to evidence-informed medicine.

Here's an anecdote. I took an ACE inhibitor for 2 years and became severely affected by persistent and violent coughing fits. Then I was put on a hydrochlorothiazide diuretic which affected my libido. Then an angiotensin II receptor antagonist and I was plagued by a constant stream of colds from October to March over three years. Worse quality of life. I now find I can manage my hypertension well by non-pharmacological means, including a small dose of potassium. Yes, I know anecdote is not good evidence for society at large, but for me my own sample of one is excellent evidence. For you? Well, you believe it or you don't.

But allow that many people seek alternatives because they wish to avoid the iatrogenic effects of pharmaceutical medicines.

Popularity is a measure of popularity not efficacy. So people like fast cars, doesn't make them good for the enviornment or consequently the longterm quality of life of the owners.

People like many things that are not nessarily good for them, cigarettes, alcohol, recreational drugs, the sales pitches from con artists

Choosing osteopathy is not like choosing a fast car or to smoke cigarettes. People choose osteopathy because they think it might improve their health; whereas they know smoking cigarettes is not going to. The motivations are completely different. No, the popularity of osteopathy is not a measure of its efficacy, but it is a measure of perceived or expected efficacy which derives from some form of "evidence" (the personal experience of a trusted friend or relative). Let people make their own minds up about what kind of evidence they deem acceptable.

Where there are proven effective therapies, the minimum standard should be equivalent efficacy.

The minimum standard should be minimal risk and absence of misleading claims.

Where disbaled children are being abused by the collusion of charlatans (or deluded individuals) and desperate parents, greater safeguards should be in place.

Any exploitation of vulnerable patients is deplorable.

As in most things, also in regulation there is a medium to be drawn. Too little regulation and some will be duped and harmed. Too much and many who might have been helped to a greater extent will continue to suffer. Patient choice is important. Over-regulation effectively implies that people are unable to make informed decisions. Information then is the key, and I suppose websites like this may help raise awareness of issues such as the fallibility of perceptions and levels of evidence.

Osteopathy is a low risk intervention and many patients say it works for them. The people who present to osteopaths have deemed acceptable the informally reported evidence from a sample of one. Some osteopaths possibly make misleading claims just as do some doctors and some of all groups of people. This is obviously wrong but it should not damn the whole profession. Personally I would object strongly if any government limited my right as a patient to experiment with possible solutions to my own health problems. Why should I not weigh up what practitioners tell me in the light of other information available to me and make a free decision? I trust them or I don't. This may boil down to gut instinct, which I seem to remember reading has been shown to be quite a good way of decision-making. (No I don't have a reference). Why not give osteopathy a try with your personal sample of one? It would be a low risk experiment.

Smith

14th March 2009, 10:24 AM

What you suggest is wrong. Non-science-based "medicine" favored bleeding, scalding, treppaning, emetics, purgatives etc. that did more harm than good. Medicine really started to advance only after we realized that simple, uncontrolled observation fools us.

I am in favour of science-informed medicine. I am not in favour of evidence-shackled medicine. If a medicine, method or technique is suspected harmful beyond a certain level of risk and with a reasonable degree of evidence, it should be restricted or withdrawn. If a medicine, method or technique is proven worthless beyond reasonable doubt, it should not be made available. But if there is no evidence that a medicine, method or technique is harmful or worthless, and there is reasonable evidence, even anecdotal, that it is effective, it should be available.

Interestingly, osteopathy was developed and gained initial popularity as a reaction to the methods you mention. It was seen as a method based on a reasoned analysis of problems in contrast to the trial-and-error, blunderbuss or trial-by-poison methods of the era. Osteopathy is still popular with many as an alternative to iatrogenic modern drugs. (Others see it as complementary).

Smith

14th March 2009, 10:28 AM

To address another aspect of this question - what do you do when evidence is limited? The answer is to objectively evaluate and rate the available evidence (even if that comes from anecdotes) and where the evidence is weak to agree a common approach based essentially on best guess. These are called guidelines. The trick is having identified areas of lack of evidence, to ensure that research is focused on those areas with poor quality evidence, so that the next set of guidelines on the same subject is based o higher quality evidence.

You may wonder why standardise approach if there very poor evidence. The answer lies in registeries of outcome. Anyone practicioner performs a limited number of treatments, thus cannot really see if the approach used is as good as others better, or worse. With standardisation, evidence can be accumulated from many practicioners, this allows you you assess the likely size of study you would need to prove that any alternative approach is better, for the purpose of proper studies.

That's informative. I'll think about it over the weekend. Could you remind me what is meant by "registry" in this context?

Pebble

14th March 2009, 11:03 AM

How much of the improvement in quality of life and longevity can be attributed to lifestyle changes? What about general increases in healthcare spending rather than the type of healthcare received? What if we throw all-causes morbidity and mortality into the equation in these groups?

All cause mortality has been the primary endpoint for heart failure trails for the past 20 years. The reduction in all cause mortality for each of the interventions mentioned varies between 15 & 35%. The annual non-evidence based treatment mortality varying from 10% for asymptomatic patients through to 70% for the severely symptomatic. The all cause mortality has fallen to less than 5% for asymptomatic and mildly symptomatic and 20% for severely symptomatic patients.

Secondary endpoints have included quality of life assessments (Minnesota heart failure questionnaire) and all cause hospitalisations, these have also been reduced.

Because we now have effective therapies, most hospitals and many larger GP surgeries run nurse led heart failure clinics where the 'softer' side of being nice to the patient and ensuring seamless multidisciplinary care is addressed - this is now an area of active research, and I agree needs considerable improvement.

COLOR=black]But allow that many people seek alternatives because they wish to avoid the iatrogenic effects of pharmaceutical medicines.[/COLOR]

The problem with transparency is that people know the down side as well as the upside. Cough with ACE inhibitors for example occurs in 3 - 6% of patients, it is also common with placebo in heart failure trials, so without large trials no one would know that the ACE inhibitor was the cause. So claims that alternative medicine is associated with less side effects is based on ignorance and assumption rather than rigorous trials large enough and long enough to identify problems.

Choosing osteopathy is not like choosing a fast car or to smoke cigarettes. People choose osteopathy because they think it might improve their health; whereas they know smoking cigarettes is not going to.

In the 1930s and 1940s people were actively encouraged to smoke to improve their cough. It was recommended for tuberculosis to clear the chest. So just because something is portrayed as good for you doesn't mean it is.

minimum standard should be minimal risk and absence of misleading claims.

So I would put it to you that to claim that osteopathy is good for asthma is misleading (as the evidence does not support this claim). To say that some patients have reported that their asthma improved after treatment by an osteopath, and that some small uncontrolled trials support this while others do not, would be OK.

That's informative. I'll think about it over the weekend. Could you remind me what is meant by "registry" in this context?

A registry is where data on individual patient populations are collected prospectively, the intervention is standardised, and the outcome (mortality, hospitalisations, adverse effects and improvements by some semi objective measure is documented over a pre-specified period of time.

The result is data that can be used to compare the outcome with any novel treatment approach. Where initial data from a novel approach suggests superiority, then the predicted size of effect can be estimated, so the size and lenght of trial required to find out if this is true determined.

Registeries are also very useful for planning the 'softer' side of care, how many echocardiograms should one be able to provide for a population of 100,000 so that all potential heart failure patients can be readily diagnosed? If a nurse will spend 15 hours per year with each advanced heart failure patient, how many nurses will be needed to ensure care is available? etc.

Mojo

14th March 2009, 11:35 AM

I see nothing wrong with the desire that all medicine should be evidence based medicine.

Microfascist (http://dcscience.net/holmes-deconstruction-ebhc-06.pdf)!

Smith

14th March 2009, 11:39 AM

Blue Wode

14th March 2009, 11:59 AM

Smith wrote:

…for me my own sample of one is excellent evidence. For you? Well, you believe it or you don't.

-snip-

Why should I not weigh up what practitioners tell me in the light of other information available to me and make a free decision? I trust them or I don't. This may boil down to gut instinct, which I seem to remember reading has been shown to be quite a good way of decision-making. (No I don't have a reference).
It would be interesting to know what you think of this reference:

Those who cast doubt on fringe treatments are frequently dismissed with the rejoinder, "I don't care what your research studies say; I know it worked for me."

It is well established, however, that this kind of intuitive judgement often leads to seriously flawed conclusions. [56,57] Unfortunately, the typical purveyor and purchaser of unproven therapies is insufficiently aware of the many perceptual and cognitive biases that can lead to faulty decisions when we depend on personal experience to decide what has caused a disease or whether a therapy "has worked" or not.

-snip-

The pioneers of the scientific revolution were aware of the large potential for error when informal reasoning joins forces with our penchant for jumping to congenial conclusions.

By systematizing observations, studying large groups rather than a few isolated individuals, instituting control groups, and trying to eliminate confounding variables, these innovative thinkers hoped to reduce the impact of the frailties of reasoning that lead to false beliefs about how the world works.

None of these safeguards exists when we base our decisions merely on a few satisfied customers' personal anecdotes - unfortunately, these stories are the "alternative" practitioner's stock in trade.

Psychologists interested in judgmental biases have repeatedly demonstrated that human inference is especially vulnerable in complex situations, such as that of evaluating therapeutic outcomes, which contain a mix of interacting variables and a number of strong social pressures.

Add a pecuniary interest in a particular outcome, and the scope for self-delusion is immense.

Beyerstein, B. Social and judgmental biases that make inert treatments seem to work. Sci Rev Altern Med. 1999;1:20–33.

More…
http://sram.org/0302/bias.html (http://sram.org/0302/bias.html)

Pebble

14th March 2009, 01:15 PM

I agree with this statement.

Misleading or not then?

http://www.liverpoolosteopaths.co.uk/osteopathy_faq/index.htm

"Q. Can osteopathic treatment be helpful in treating children.
A. Cranial osteopathic treatment can be very successful in treating many problems in children, the more common conditions being, colic, asthma, glue ear, sinus problem."

"Q. I suffer chronic sinusitis can osteopathy help.
A. Yes cranial osteopathy can be very successful in treating chronic sinus conditions both in children and adults"

The whole presentation gives a clearly misleading impression, and is based on the use of the word 'can' which implies the presence of evidence. Even if one substituted the more realistic word 'may' the presentation is still designed to sell this approach not to encourage informed decision making.

Smith

14th March 2009, 04:10 PM

Smith wrote:
It would be interesting to know what you think of this reference:

Beyerstein, B. Social and judgmental biases that make inert treatments seem to work. Sci Rev Altern Med. 1999;1:20–33.

More…
http://sram.org/0302/bias.html

When all is said, "when a hunch and a fact collide, the fact wins".

On the other hand I should hate to "fondly point to 'facts' while... forced to dismiss 'values' as somehow unscientific". http://dcscience.net/holmes-deconstruction-ebhc-06.pdf

And notwithstanding the fallibility of my judgement, I defend my right as a patient to make the call.

The paper at http://sram.org/0302/bias.html (http://sram.org/0302/bias.html) is interesting, not without its questionable elements.

Incidentally, the latter paper is largely to do with what Beyerstein calls "fringe" therapies. I do not think osteopathy can be considered such. Beyerstein writes:

"So, if an unorthodox therapy:
(a) is implausible on a priori grounds (because its implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in physics, chemistry, or biology);
(b) lacks a scientifically acceptable rationale of its own;
(c) has insufficient supporting evidence derived from adequately controlled outcome research;
(d) has failed in well-controlled clinical studies done by impartial evaluators and has been unable to rule out competing explanations for why it might seem to work in uncontrolled settings; and
(e) should seem improbable, even to the lay person, on "common sense" grounds;

why would so many well-educated people continue to sell and purchase such a treatment?"

Osteopathy is under-researched (c), but my sense is that it does not tick boxes (a), (b) and (e).

Smith

14th March 2009, 04:24 PM

So I would put it to you that to claim that osteopathy is good for asthma is misleading (as the evidence does not support this claim). To say that some patients have reported that their asthma improved after treatment by an osteopath, and that some small uncontrolled trials support this while others do not, would be OK.

Misleading or not then?

I agree with both sentences. The first kind of claim is misleading. The second is not.

"Q. Can osteopathic treatment be helpful in treating children.
A. Cranial osteopathic treatment can be very successful in treating many problems in children, the more common conditions being, colic, asthma, glue ear, sinus problem."

"Q. I suffer chronic sinusitis can osteopathy help.
A. Yes cranial osteopathy can be very successful in treating chronic sinus conditions both in children and adults".

If formal research evidence is lacking, these claims as they stand are misleading because they do not make clear on what basis they are made.

Blue Wode

15th March 2009, 08:52 AM

The paper at http://sram.org/0302/bias.html (http://sram.org/0302/bias.html) is interesting, not without its questionable elements.

Incidentally, the latter paper is largely to do with what Beyerstein calls "fringe" therapies. I do not think osteopathy can be considered such. Beyerstein writes:

"So, if an unorthodox therapy:
(a) is implausible on a priori grounds (because its implied mechanisms or putative effects contradict well-established laws, principles, or empirical findings in physics, chemistry, or biology);
(b) lacks a scientifically acceptable rationale of its own;
(c) has insufficient supporting evidence derived from adequately controlled outcome research;
(d) has failed in well-controlled clinical studies done by impartial evaluators and has been unable to rule out competing explanations for why it might seem to work in uncontrolled settings; and
(e) should seem improbable, even to the lay person, on "common sense" grounds;

why would so many well-educated people continue to sell and purchase such a treatment?"

Osteopathy is under-researched (c), but my sense is that it does not tick boxes (a), (b) and (e).
Nevertheless, whilst it remains under-researched - and not forgetting that recent a rigorous examination of osteopaths’ practices revealed that

many also claim to treat other conditions such as asthma, ear infection and colic,

[Ref. Singh and Ernst]
http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=17 74&ICO=HEALTH&ICL=TOPART (http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=17 74&ICO=HEALTH&ICL=TOPART)

it cannot be viewed as anything other than a very close relative of fringe therapies, and, as such, should be used with great caution.

Smith

15th March 2009, 10:03 AM

Quote:
many also claim to treat other conditions such as asthma, ear infection and colic,

[Ref. Singh and Ernst]
http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=17 74&ICO=HEALTH&ICL=TOPART (http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=17 74&ICO=HEALTH&ICL=TOPART)

I get error 503 with this link. How many is many? "Many" others do not. "Claiming to treat" says nothing about information provided to the patient beforehand.

it cannot be viewed as anything other than a very close relative of fringe therapies, and, as such, should be used with great caution.

I notice how you use value judgements. I disagree that it must be regarded as a close relative of therapies such as crystal healing or aura cleansing.

Mojo

15th March 2009, 10:34 AM

many also claim to treat other conditions such as asthma, ear infection and colic,

[Ref. Singh and Ernst]
http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=557946&in_page_id=17 74&ICO=HEALTH&ICL=TOPARTI get error 503 with this link.
Works fine for me, but if you want to Google it it's an article called "Are we being hoodwinked by alternative medicine? Two leading scientists examine the evidence".
How many is many? "Many" others do not. "Claiming to treat" says nothing about information provided to the patient beforehand.
If you want to know about the sort of information osteopaths provide to prospective patients, perhaps the "fact sheets" provided to promote* osteopathy by the General Osteopathic Council, a statutory regulatory body to which all UK osteopaths belong, would be a good place to start. For example this one: http://www.osteopathy.org.uk/about_osteo/Babies_Children.pdf

Many common problems suffered by babies and children can be treated effectively with
osteopathy.
Problems often suffered by babies:
• crying and irritability, especially when lying down.
• feeding difficulties.
• sickness, colic and wind.
• sleep disturbances.
Problems often suffered by older children:
• musculo-skeletal problems.
• susceptibility to infections and a depleted immune system.
• ear infection, sometimes with a loss of hearing and ‘glue ear’.
• sinus and dental problems, with a constantly blocked or runny nose.
• behavioural problems and learning difficulties, including poor concentration, fidgeting,
difficulty in sitting still and hyperactivity.
• headache, other aches and pains.
• asthma and vulnerability to chest infections.
Osteopathy can also help children suffering from cerebral palsy or Down’s Syndrome.

*ETA: do I hear "conflict of interest"?

Smith

15th March 2009, 05:46 PM

If you want to know about the sort of information osteopaths provide to prospective patients, perhaps the "fact sheets" provided to promote* osteopathy by the General Osteopathic Council, a statutory regulatory body to which all UK osteopaths belong, would be a good place to start. For example this one: http://www.osteopathy.org.uk/about_osteo/Babies_Children.pdf

I am familiar with this information and I have written to the General Osteopathic Council to voice my concerns.

*ETA: do I hear "conflict of interest"?

You are quite right. My view is that it is unacceptable that a regulatory body should also have been given (statutorily) the duty to promote the profession. I believe this will change in the near future.

Smith

15th March 2009, 05:52 PM

it... ...should be used with great caution.

Of course it is wise to regard any kind of medical treatment with great caution.

Smith

15th March 2009, 06:07 PM

If you want to know about the sort of information osteopaths provide to prospective patients... etc.

To come back to this, my experience of medical doctors over the past few years is that none of the ones I have consulted (several) have spontaneously provided any information about the proofs of benefit, or the risks, or the cautions, or alternative treatments (even pharmaceutical) with regard to the drugs they have wanted to prescribe me. When I have brought such questions up, either the doctor has been poorly-informed, or the responses have been cursory.

Blue Wode

15th March 2009, 07:26 PM

Originally Posted by Blue Wode http://www.ukskeptics.com/forum/images/buttons/viewpost.gif (http://www.skeptics.org.uk/forum/showthread.php?p=57264#post57264)
it... ...should be used with great caution.

Of course it is wise to regard any kind of medical treatment with great caution.

But the greatest caution, it would seem, should be applied to CAM therapies:

In a consumer rights situation, the rights of the consumer must be weighted higher than the rights of the seller. The consumer has a right to know what they are buying, and the seller does not have the right to deceive. One must not be tolerant of untruth. "Truth in advertising" isn't just a slogan. It is an expression that reveals a fundamental understanding of freedom and democracy. The product being sold must be labelled correctly, otherwise the free choice exercised by the buyer turns out to be an illusion.

Consumers have a right to freedom of choice, but they also deserve protection. This is best done, not by limiting consumers' rights, but by limiting the possible ways that quacks can mislead them. sCAM practitioners should be required to adhere to strict laws regarding truth in advertising and acceptable marketing practices.

http://www.skepticreport.com/medicalquackery/freedomchoice.htm (http://www.skepticreport.com/medicalquackery/freedomchoice.htm)

It’s certainly going to be interesting to see how long it takes the GOsC to tighten things up (if at all).

Pebble

15th March 2009, 10:34 PM

To come back to this, my experience of medical doctors over the past few years is that none of the ones I have consulted (several) have spontaneously provided any information about the proofs of benefit, or the risks, or the cautions, or alternative treatments (even pharmaceutical) with regard to the drugs they have wanted to prescribe me. When I have brought such questions up, either the doctor has been poorly-informed, or the responses have been cursory.

Clearly no one but you are privy to all the details, so much of what is stated has to be taken on faith. However, first there is the issue of governance. Medics are not allowed practice without appraisal, requiring 50 hours minimum per year education. Further there is clear guidance (from NICE etc) about what practice is acceptable and what is not. So standards need not necessarily be defined by the individual practicioner, but failure to adhere is actionable.

Secondly, that which may be regarded as pivotal information by you may be regarded as irrelevant by the doctor, so how are we to assess the stated level of incompetence, versus differences in perception?

For example, the list of side effects in the BNF from a drug simply relate to the adverse effects noted more in more than 1% of trial participants, or of serious nature occurring during the trial or reported through the yellow card system, whether these are actually attributable to the drug or not. As a result the known side effects of any given drug may diffir significantly from those recorded in the BNF.

So while your experiences have been adverse and it may be that you have met only incompetents, other explanations may exist on the information provided to date.

Smith

16th March 2009, 06:59 PM

But the greatest caution, it would seem, should be applied to CAM therapies:

Quote:
In a consumer rights situation, the rights of the consumer must be weighted higher than the rights of the seller. The consumer has a right to know what they are buying, and the seller does not have the right to deceive. One must not be tolerant of untruth. "Truth in advertising" isn't just a slogan. It is an expression that reveals a fundamental understanding of freedom and democracy. The product being sold must be labelled correctly, otherwise the free choice exercised by the buyer turns out to be an illusion.

Consumers have a right to freedom of choice, but they also deserve protection. This is best done, not by limiting consumers' rights, but by limiting the possible ways that quacks can mislead them. sCAM practitioners should be required to adhere to strict laws regarding truth in advertising and acceptable marketing practices.

http://www.skepticreport.com/medicalquackery/freedomchoice.htm (http://www.skepticreport.com/medicalquackery/freedomchoice.htm)

I fail to see how this quoted opinion about advertising standards backs up your assertion. Personally, I would think it natural to exert the greatest caution where there is the greatest potential for physical harm.

Also, it is clouding the issue to wrap up osteopathy part and parcel with "CAM" therapies. I state again my view that to attempt to present osteopathy as being fundamentally similar to therapies such as "aura-cleansing" (to pick one) with regards to training, knowledge base, governance and professionalism is very very wrong.

Secondly, I was rightly pulled up for mis-spelling "skeptic" in an earlier post. In the context of a discussion about osteopathy, this quotation, which tendentially uses pejoratrive terms and mischievous word-distortion does not make for impartial debate.

Smith

16th March 2009, 07:28 PM

However, first there is the issue of governance. Medics are not allowed practice without appraisal, requiring 50 hours minimum per year education. Further there is clear guidance (from NICE etc) about what practice is acceptable and what is not. So standards need not necessarily be defined by the individual practicioner, but failure to adhere is actionable.

The GOsC is responsible for governance in osteopathy. It is no longer elected but appointed by the government. UK osteopaths are required to complete 30 hours Continuing Professional Development (CPD) per year. Periodic revalidation is just round the corner. There is a detailed code of practice, which is currently under review. A rigorous and effective disciplinary system is in place.

Secondly, that which may be regarded as pivotal information by you may be regarded as irrelevant by the doctor, so how are we to assess the stated level of incompetence, versus differences in perception?

Sorry, any concern that a patient has with regard to the proposed treatment plan is relevant.

For example, the list of side effects in the BNF from a drug simply relate to the adverse effects noted more in more than 1% of trial participants, or of serious nature occurring during the trial or reported through the yellow card system, whether these are actually attributable to the drug or not. As a result the known side effects of any given drug may diffir significantly from those recorded in the BNF.

I'm confused. Are you saying that it is permissible for a doctor to be ignorant of the "known" risks of a drug he/she prescribes, or not to relay that information to the patient? Or that risks are often not known?

Osteopaths are required by their code of practice spontaneously to provide information about known risks of treatment and to seek informed consent to treat, at each step of the way.

Further with regard to provision of information, how many doctors take the time to explain to patients that although the drug they are prescribing has been demonstrated to be effective in a percentage of patients, there is the remaining percentage in which it is typically ineffective? I think I can guess the answer.

So I agree, advertising standards for osteopathy, but equivalent ones for drug medicine, please.

Pebble

16th March 2009, 08:03 PM

The GOsC is responsible for governance in osteopathy. It is no longer elected but appointed by the government. UK osteopaths are required to complete 30 hours Continuing Professional Development (CPD) per year. Periodic revalidation is just round the corner. There is a detailed code of practice, which is currently under review. A rigorous and effective disciplinary system is in place.

Window dressing unless backed by evidence based guidance.

, any concern that a patient has with regard to the proposed treatment plan is relevant.

Nice in theory, but reality tells us there are some patients who have overblown concerns that have no basis in reality. The most rudimentry approach is to provide advice based on the best available evidence and if the patient does not take your advice that is up to them. At the other end of the scale all concerns are dealt with by providing the evidence base and discussing the merits of each main trial and the balance of evidence favoring the conclusion you have come to. The reality is somewhere between, obviously you and your doctor disagreed on where that line should be drawn.

confused. Are you saying that it is permissible for a doctor to be ignorant of the "known" risks of a drug he/she prescribes, or not to relay that information to the patient? Or that risks are often not known?

.

Here you are simply missing the point. The known side effects may differ from those recorded in the accessible source of information, this can lead to very tedious discussions that achieve very little. It is indeed incumbent on the medical profession (either the doctor or the pharmacist - not necessarily both) to ensure that the patient is made familiar with the common and serious side effects as well as likely interactions of prescribed medicines.

In respect of the fact that all evidence based drugs have an incremental benefit over the comparator, it is missing the point to then suggest that this means the drug only works for some. If a drug reduces the mortality in heart failure by 30% from 10% per annum to 7% per annum, one could assert (incorrectly) that only 3% benefit in any one year. This is to confuse study end points with patient benefit. Patient benefit is often an unknown quantity, only the study end points are evidence based. Patient benefit may be far greater, as is assumed to be the case for non evidence based therapies - e.g. osteopathy.

Blue Wode

16th March 2009, 10:42 PM

But the greatest caution, it would seem, should be applied to CAM therapies:

Quote:
In a consumer rights situation, the rights of the consumer must be weighted higher than the rights of the seller. The consumer has a right to know what they are buying, and the seller does not have the right to deceive. One must not be tolerant of untruth. "Truth in advertising" isn't just a slogan. It is an expression that reveals a fundamental understanding of freedom and democracy. The product being sold must be labelled correctly, otherwise the free choice exercised by the buyer turns out to be an illusion.

Consumers have a right to freedom of choice, but they also deserve protection. This is best done, not by limiting consumers' rights, but by limiting the possible ways that quacks can mislead them. sCAM practitioners should be required to adhere to strict laws regarding truth in advertising and acceptable marketing practices.

http://www.skepticreport.com/medicalquackery/freedomchoice.htm (http://www.skepticreport.com/medicalquackery/freedomchoice.htm)

I fail to see how this quoted opinion about advertising standards backs up your assertion. Personally, I would think it natural to exert the greatest caution where there is the greatest potential for physical harm.

Well, aren’t CAM therapists much more likely to mislead than conventional healthcare providers due to there being a lack of convincing evidence to back up their claims?

And what systems do they have in place to monitor harms to help enable them to make valid risk/benefit assessments?

Also, it is clouding the issue to wrap up osteopathy part and parcel with "CAM" therapies. I state again my view that to attempt to present osteopathy as being fundamentally similar to therapies such as "aura-cleansing" (to pick one) with regards to training, knowledge base, governance and professionalism is very very wrong.
In their book, Trick or Treatment? Alternative Medicine on Trial, impartial scientists, Simon Singh and Edzard Ernst, clearly consider osteopathy to be an ‘alternative’ medicine. Indeed, they evaluate it in the same section as therapies like colonic irrigation, crystal therapy, cupping, ear candling, Feng Shui, magnet therapy, oxygen therapy, reflexology, reiki, and spiritual healing.

Secondly, I was rightly pulled up for mis-spelling "skeptic" in an earlier post. In the context of a discussion about osteopathy, this quotation, which tendentially uses pejoratrive terms and mischievous word-distortion does not make for impartial debate.
The quote was in context and I remain unrepentant about posting it.

tolman

17th March 2009, 11:20 PM

Further with regard to provision of information, how many doctors take the time to explain to patients that although the drug they are prescribing has been demonstrated to be effective in a percentage of patients, there is the remaining percentage in which it is typically ineffective? I think I can guess the answer.
Surely, the fact that a particular medicine might not work for a given person is pretty much implicit in the pretty universal "Try this, and come back if it doesn't clear up" approach taken by most proper doctors when they prescribe something?

Smith

19th March 2009, 07:39 AM

Surely, the fact that a particular medicine might not work for a given person is pretty much implicit in the pretty universal "Try this, and come back if it doesn't clear up" approach taken by most proper doctors when they prescribe something?

True. But these words could have several interpretations, e.g. the medicine is expected to work, the medicine likely won’t work, the intervention is hit-or-miss. But I expect many osteopaths take a similar approach, although they talk it through a little more. The points I wanted to make are that: (a) medical doctors are at least as guilty of giving vague and unqualified information as are osteopaths, and (b) pharmaceutical medicine is as open to criticism regarding information provided to patients as is osteopathy.

Smith

19th March 2009, 07:45 AM

Well, aren’t CAM therapists much more likely to mislead than conventional healthcare providers due to there being a lack of convincing evidence to back up their claims?

Remember that whether evidence is good or convincing is a judgement and will vary according to one’s value system. Whether a patient is misled or not might easily depend on the depth of information provided. And as has been stated in another post, whereas osteopaths typically provide quite a lot of verbal information to patients during a consultation, doctors typically do not.

And what systems do they have in place to monitor harms to help enable them to make valid risk/benefit assessments?

The first step will involve primary information gathering: http://www.brighton.ac.uk/ncor/research_opps/index.htm
Also “NCOR is currently in the process of developing a standardised data collection tool for osteopathy”: http://www.brighton.ac.uk/sohp/research/groups/ncor.php

In their book, Trick or Treatment? Alternative Medicine on Trial, impartial scientists, Simon Singh and Edzard Ernst, clearly consider osteopathy to be an ‘alternative’ medicine. Indeed, they evaluate it in the same section as therapies like colonic irrigation, crystal therapy, cupping, ear candling, Feng Shui, magnet therapy, oxygen therapy, reflexology, reiki, and spiritual healing.

1) Why should we assume they are impartial?

2) Categories depend upon inclusion criteria. Just because osteopathy is supposed to share characteristics with reiki for the purposes of Ernst and Singh’s survey (I suppose here the criterion was “anything other than orthodoxy”), this does not necessarily mean we should consider them together for the purposes of our own discussion. Characteristics of osteopathy which make it distinct from some other therapies they mention and ought to be acknowledged in our own discussion are, for example:-
· It is based on modern knowledge of anatomy and physiology.
· Training takes 4 or 5 years full-time.
· Osteopaths are taught pathology, clinical and diagnostic methods, and history taking and examination all to a high level. It might surprise you to learn that nowadays they are also taught research methods.
· It is governed by a statutory regulating body.
· Osteopaths have to adhere to a detailed and strict code of practice.
· Increasingly osteopaths are becoming actively involved in formal scientific research.

So I will not talk about “CAM therapists” in general in a debate specifically about osteopathy.

Smith

19th March 2009, 08:04 AM

Window dressing unless backed by evidence based guidance.

The GOsC is vocal in urging osteopaths to work towards an evidence-based footing. You already know my views on what that should and should not mean. Let me remind you that the GOsC is not an association of osteopaths looking after their own interests but a government appointed body which ultimately answers to the public.

The reality is somewhere between, obviously you and your doctor disagreed on where that line should be drawn.

Doctors, several, without exception. Yes, I thought that minimal information about benefits and risks should be mandatory. They assumed none were necessary. My point is that it is unfair to rap osteopaths for unqualified statements such as “This treatment can help with your complaint”, when doctors do likewise, or worse, presume that explanations are unnecessary because it must be accepted by all that the treatments they prescribe pass risk-benefit assessment. You might argue that doctors don’t need to justify their prescriptions to the patient because they are evidence-based. In my opinion the patient has the right to be allowed to make that judgement. One could argue, too, that osteopaths' treatments are evidence-based, the kind of evidence being of a different order. Statistical evidence from RCTs is “better”? Let the patient decide. “The patient is not qualified to judge?” If they are provided with information, they will be better qualified.

The known side effects may differ from those recorded in the accessible source of information,

Information about known side effects may not be accessible to doctors. That’s OK is it?

this can lead to very tedious discussions that achieve very little.

Discussing things with the patient, how very inconvenient! Achieve very little? That sounds like an unfounded assumption to me. Difference between dependency and agency? Between non-compliance and collaboration? Osteopaths talk to their patients… odd notion!

In respect of the fact that all evidence based drugs have an incremental benefit over the comparator, it is missing the point to then suggest that this means the drug only works for some. If a drug reduces the mortality in heart failure by 30% from 10% per annum to 7% per annum, one could assert (incorrectly) that only 3% benefit in any one year. This is to confuse study end points with patient benefit. Patient benefit is often an unknown quantity, only the study end points are evidence based.

I appreciate that a 30% reduction in heart failure mortality shown in a population does not translate into a known benefit this year for patient Smith. But the typical patient doesn’t know that, because he isn’t told. He isn’t told either about the kind of risk reduction expected in populations. Or the X% risk of Y side-effect. So he/she cannot make an informed decision. Mis-selling?

Patient benefit may be far greater, as is assumed to be the case for non evidence based therapies - e.g. osteopathy.
So, patient benefit is unknown yet assumed both in osteopathy and in conventional medicine. What pharmaceutical medicine appears to know that osteopathy doesn’t is the population level order of beneficial effects. Please take into account that with respect to a profession such as osteopathy the pharmaceutical industry is vastly advantaged in gaining such information.

Pebble

19th March 2009, 08:34 AM

Discussions with patients:

First there is plenty of data to show that a large minority of the population do not understand percentages, as for the concept of relative risk - this works very well during discussions in private practice, but in general clinics raising such issues often leads to the next question - what would you advise, or if it were your mother what would you do? So I do try, but experience tells me that I do this more to try to be transparent, than because it actually helps decision making in most instances.

Fine in a surgery where one has 20 min per patient.

Now lets move to the real world. 5 minute GP slots. Essential because the system is designed to provide minimum cover for all with ostensibly rapid access. The individual patient may feel that while there the only thing that matters is that they get Rolls Royce care, the doctor may agree, but the system is not designed to deliver this, it is in effect supermarket medicine.

Next to patient benefit versus knowledge base. Conventional v osteopathy. There are unknowns eg total patient benefit, but the level of understandig of what this might be is of a different order of magnitude. ACE inhibitors for heart failure: reduce mortality by 20 - 30%, reduce hospitalisations by 15 - 25%, reduce rate fo development of diabetes by 15 - 20%, reduce rate of myocardial infarction by 15 - 20%, reduce rate of developement of renal failure by 10 - 20%, increase effort capacity and observed LV function by variable amounts. Cause dose related cough in 3 - 6%, reversible renal impairment in 0.5 - 2%, allergy, angio-oedema and gastrointestinal upset rarely. (the BNF lists many more side effects seen so rarely or unrealted but just happened in trials). What is the total benefit in Mr Smith? I don't know do you?

tolman

19th March 2009, 09:38 AM

True. But these words could have several interpretations, e.g. the medicine is expected to work, the medicine likely won’t work, the intervention is hit-or-miss.
That's not really several interpretations, that's just different vague points on a probability line.
Whether or not a patient is actually prescribed anything, for problems where the patient can tell if things are getting worse (or failing to get better), all that's really needed is a suggestion that the suggested course of action isn't infallible, and that the person should return if things get worse (or fail to get better). Especially when further consultations are free, that seems a reasonable way of dealing with a large workload.

If we were going to pay privately for GPs, or collectively employ many more public ones, I guess we could have longer debriefs at the end of consultations.

Certainly, one of the advantages of alternative medicine where the particular person involved does actually have some kind of specialist knowledge is that they may well have the time/experience to be able to spot things that a [generalist] GP might miss.

Blue Wode

19th March 2009, 11:07 AM

Remember that whether evidence is good or convincing is a judgement and will vary according to one’s value system. Whether a patient is misled or not might easily depend on the depth of information provided.
Well, let’s not forget what can drive the value systems of CAM therapists…

“Informing patients about the best scientific evidence will, in some cases, mean telling them about the lack of scientifically proven benefit and the presence of potential risks, yet this would be overtly contrary to the personal (financial) interests, beliefs and emotional attitudes of CAM practitioners."
http://journals.medicinescomplete.com/journals/fact/current/fact0803a02t01.htm (http://journals.medicinescomplete.com/journals/fact/current/fact0803a02t01.htm)

Smith wrote

And what systems do they have in place to monitor harms to help enable them to make valid risk/benefit assessments?

The first step will involve primary information gathering: http://www.brighton.ac.uk/ncor/research_opps/index.htm (http://www.brighton.ac.uk/ncor/research_opps/index.htm)

Also “NCOR is currently in the process of developing a standardised data collection tool for osteopathy”: http://www.brighton.ac.uk/sohp/research/groups/ncor.php (http://www.brighton.ac.uk/sohp/research/groups/ncor.php)

But the GOsC has supposedly been protecting, promoting and maintaining the health, safety and wellbeing of members of the public since May 2000. Why, after *nine* years, are you saying “the first step will involve primary information gathering”? Why hasn’t that been done already?

Smith wrote:

Why should we assume they [Singh and Ernst] are impartial?

Because Singh and Ernst do not depend on the ‘right’ outcomes in studies in order to earn a living.

Smith wrote:

Categories depend upon inclusion criteria. Just because osteopathy is supposed to share characteristics with reiki for the purposes of Ernst and Singh’s survey (I suppose here the criterion was “anything other than orthodoxy”)
Yes, it would seem so – in which case they are correct to include osteopathy as a CAM.

Smith wrote:

...this does not necessarily mean we should consider them together for the purposes of our own discussion. Characteristics of osteopathy which make it distinct from some other therapies they mention and ought to be acknowledged in our own discussion are, for example:-

It is based on modern knowledge of anatomy and physiology.
Training takes 4 or 5 years full-time.
Osteopaths are taught pathology, clinical and diagnostic methods, and history taking and examination all to a high level. It might surprise you to learn that nowadays they are also taught research methods.
It is governed by a statutory regulating body.
Osteopaths have to adhere to a detailed and strict code of practice.
Increasingly osteopaths are becoming actively involved in formal scientific research.

That list is fairly meaningless when you consider that chiropractors, who are also regulated by statute in the UK, make more or less the same claims and their practices continue to be riddled with quackery.

Smith wrote:

So I will not talk about “CAM therapists” in general in a debate specifically about osteopathy.
I will.

Smith

19th March 2009, 11:26 AM

What is the total benefit in Mr Smith? I don't know do you?

No, I do not.

Off subject, but do we have any explanation for the apparent effect of ACE inhibitors in reducing the incidence of diabetes?

Smith

19th March 2009, 11:53 AM

Well, let’s not forget what can drive the value systems of CAM therapists…

“Informing patients about the best scientific evidence will, in some cases, mean telling them about the lack of scientifically proven benefit and the presence of potential risks, yet this would be overtly contrary to the personal (financial) interests, beliefs and emotional attitudes of CAM practitioners."
http://journals.medicinescomplete.com/journals/fact/current/fact0803a02t01.htm (http://journals.medicinescomplete.com/journals/fact/current/fact0803a02t01.htm)

I think osteopaths in general are not as money-minded as you might like to portray them. Otherwise I agree with you that osteopaths should tell their patients what scientific evidence is available and its meaning, as well as telling them of other reasons why they believe the proposed treatment plan will help.

But the GOsC has supposedly been protecting, promoting and maintaining the health, safety and wellbeing of members of the public since May 2000. Why, after *nine* years, are you saying “the first step will involve primary information gathering”? Why hasn’t that been done already?

Osteopathy is evolving from a discipline based on anatomical and physiological knowledge, theory and experiential evidence, to a discipline informed by experimental evidence. Medicine too went through these steps. While this has been happening, the regulatory framework, structures and mechanisms have been set up, developed and are still evolving. It would be unrealistic to expect all this to have happened more rapidly than it has.

[quote=Blue Wode;57540]I will (talk about “CAM therapists” in general in a debate specifically about osteopathy).

Well in that case I will bow out. We could slog it out for days like this, but with that comment I really can't see the point any more. We would be talking at cross purposes. It seems you are determined to see osteopathy in a bad light and not to give credit where credit is due.

Blue Wode

19th March 2009, 01:00 PM

It seems you are determined to see osteopathy in a bad light and not to give credit where credit is due.
Did you not read the following posts which I made to this thread?

#122:

The evidence that the osteopathic approach is effective for treating back pain is reasonably sound. If, however, you receive no significant benefit then be prepared to switch to physiotherapeutic exercise, which is backed by similar evidence and which can be done in groups and therefore is more cost-effective. There is no evidence to support osteopathy for the treatment of non-musculoskeletal conditions.

http://www.skeptics.org.uk/forum/showpost.php?p=56782&postcount=112 (http://www.skeptics.org.uk/forum/showpost.php?p=56782&postcount=112)

#155:

It does appear to be true that osteopaths cause less adverse effects related to the cervical spine when compared to chiropractors. See fig.2 here: http://www.ptjournal.org/cgi/content/full/79/1/50 (http://www.ptjournal.org/cgi/content/full/79/1/50)

http://www.skeptics.org.uk/forum/showpost.php?p=56909&postcount=155 (http://www.skeptics.org.uk/forum/showpost.php?p=56909&postcount=155)

#158:

Osteopathic hands on treatment of the spine is spinal manipulation! ( not just LAHVT, but MET, soft tissue, articulation etc,
Singh and Ernst don’t make that clear, however they do say that osteopaths “place less emphasis on the spine” - something which they seem to view as being more favourable than chiropractic therapy.

http://www.skeptics.org.uk/forum/showpost.php?p=56912&postcount=158 (http://www.skeptics.org.uk/forum/showpost.php?p=56912&postcount=158)

Pebble

19th March 2009, 06:24 PM

No, I do not.

Neathly side stepping the point I was making: there is not knowing the ptoential patient benefit (despite ample evidence base) and not knowing the total patient benefit (in the absence of evidence) - they are not the sam thing.

Off subject, but do we have any explanation for the apparent effect of ACE inhibitors in reducing the incidence of diabetes?

Unknown, but as an antifibrotic, anti-apoptoticand anti-inflammatory agent, many potential mechanisms have been proposed as to how islet cell function may be preserved, and insulin sensitivity might be maintained. Currently under evaluation, so keep an eye on pubmed.

Smith

19th March 2009, 07:29 PM

Blue Wode:

Yes, I did read those small and perhaps grudging concessions the first time round. My overall impression of our own interaction is unchanged. I wouldn't like to live a life in which my own decision-making process were shackled to statistical proofs. But there you go, different people have different modi operandi...

Pebble:

Not side-stepping, honestly; acknowledging. You credit me with an evasive agility to which I am disinclined.

....

I will sign off this thread now as I think I've said all that I can usefully say. Thank you to my interlocutors, I like to learn from this kind of encounter and I think I have gained in that way.

davidrodway

20th March 2009, 08:05 PM

I’m back briefly. No time to visit all past posts but just a few comments.
Sinusitis references – if you look at the long posts I left regarding research you will probably see some relevant references there.

If not, they will probably be in some others I am digging out re osteopathy/manipulation that Prof Ernst seems to have overlooked (strange, because he does not usually omit references merely because the research is bad; as you know he points out how bad it is)

Mr Smith had a few good points and some poor ones :

While all osteopaths can talk about the failings to diagnose of their local GP, poor performance of an individual does not invalidate the whole of “orthodox “ medicine (although I wish our critics would bear this in mind when having a go at osteopathy because of the errors of a few osteopaths)

Even if orthodox medicine does deserve criticism, the failings of orthodoxy do nothing to enhance the reputation of osteopathy

GOsC and research – the points made by , I think, Bluewode were valid - the GOsC is acting now, but should have done more before. They have had over 10 years. Better late than never, its true , but still late. And it has been suggested to them about 3 years ago that we should have an adverse reaction notification system - they said then that they had not had time to implement one ( or something ), but they still have not done anything.

Its not as if they have not got the money - £700 from 4000 osteopaths per year.

Is osteopathy CAM? The only way I can see it might be is that a few ofr some osteopaths’ claims have no plausible mechanism of action and there is a lack of good research in some areas. But , I suggest, osteopaths realise these problems, recognise that they are areas we have to address, are trying to get to grips with them and will modify our practice as a result (hardly characteristics of a WOO system ). Unlike chiropractic, to deal with that point, we do not believe in mythical “subluxations” that only we can diagnose and treat, and we do not sue people over scientific/clinical matters.

This could go on and on and probably will. For now, I hope that the critics of osteopathy if they are working in the clinical field will, for example, if they ever get a letter from an osteopath about a patient, read it and consider it and not bin it or dismiss it out of hand just because they see it is from an osteopath. The osteopath will be writing to you because they have the best interests of the patient at heart, as, I am sure, do you.

One other point. The term “holistic” is much bandied about and rightly often derided. My local college uses the term on a brochure that invites the public to have their fingernails painted and legs waxed. Osteopaths therefore do not usually like the term. But I will give you an example of “Unholistic” medicine. In the GP practice next to me there is a big notice telling patients “Doctor will only deal with one of your problems at each visit” ( or words to that effect). Pity the patient with diabetes so cowed by this that they dare only mention that they feel tired, and not also mention their thirst and frequent micturition.

Pebble alluded to “supermarket medicine”. Recent newspaper stories about Stafford illustrate how right he is, and the consequences of it. I don’t think osteopathy could work in 5 minute consultations ( 15 minutes per patients is considered very fast for osteopaths). That is part of the point - osteopathy is by definition “Bespoke health care”. Even so studies like the BEAM trial seem to show that we are cost effective.

Having said that one area where research might help make us more time efficient is in definitive answers about which case history questions yield pertinent information, which clinical examinations are useful and which are redundant, and whether we need to use as many techniques as we do (perhaps all that soft tissue and articulation is unnecessary after all and we just need to do a few quick “cracks” like the chiropractors. I doubt it, but I could be wrong)

So is osteopathy WOO? I think its fair to say it straddles both camps, is mainly orthodox with varying degrees (depending on the osteopath) of WOOness. Its probably the most nonWOO of all the “CAM”s. Its about as WOO as dentistry. But that’s only my opinion.

davidrodway

24th March 2009, 07:20 PM

tolman

24th March 2009, 07:47 PM

Does 'pilot study' tend to imply a small sample?

When is a larger-scale follow up planned?

Matt

24th March 2009, 08:17 PM

Does 'pilot study' tend to imply a small sample?

When is a larger-scale follow up planned?

I'd rather see a double blind study comparing osteopathy to sham osteopathy espacially with stress related condition being measured subjectectively pressumably being more vulnerable than most to experimental biases.

I also note that they were testing multiple metrics - I hope they compensated for that in their significance calculations.

davidrodway

25th March 2009, 12:34 AM

A pilot, or feasibility study, is a small experiment designed to test logistics and gather information prior to a larger study, in order to improve the latter’s quality and efficiency. A pilot study can reveal deficiencies in the design of a proposed experiment or procedure and these can then be addressed before time and resources are expended on large scale studies. A good research strategy requires careful planning and a pilot study will often be a part of this strategy.
A pilot study is normally small in comparison with the main experiment and therefore can provide only limited information on the sources and magnitude of variation of response measures. It is unlikely, for example, that a pilot study alone can provide adequate data on variability for a power analysis to estimate the number to include in a well designed experiment.

"When is a larger-scale follow up planned? "

I do not know - why don't you ask them?

Pebble

25th March 2009, 06:02 PM

Heres one of those refences Ernst seems to have overlooked. Will search out the others when I have time. No doubt our statistics guy Pebble will provide the appropriate analysis

Henry WC Hundscheid, Manon JAE Pepels, Leopold GJB Engels, Ruud JLF Loffeld (2007) Treatment of irritable bowel syndrome with osteopathy: Results of a randomized controlled pilot study Journal of Gastroenterology and Hepatology 22 (9) , 1394–1398 doi:10.1111/j.1440-1746.2006.04741.x

Issues to consider:

Pilot study - 39 patients, 3 lost to follow up (one osteopathy)
Unblinded: Options treatment in outpatients, or in PRIVATE osteopathy clinic - unblinded patient questionaires then used to assess impact.
Unplanned: no power analysis regarded as possible
Unstandardised: As there was no known osteopathic approach for this condition, a 'black box' approach used.
Primary endpoint non significant: QOL @ 6 months 129+/- 19 v 121+/-25, the lack of effect on the primary endpoint was ignored in favor of analysis of secondary endpoint (FBDSI at 6 months).

Conclusion If you take a condition like IBS where no treatment is effective and no pathology can be defined, and you treat the patients well they feel better. There could of course be more to it, but this has not been demonstrated on the basis of this study.

davidrodway

26th March 2009, 01:10 AM

For those of you who would genuinely like to make points directly to the GOsC:

"The General Osteopathic Council have made this consultation process quite open. All three key consultation documents (Osteopathic Practice Standards, Revalidation, Osteopathic Practice Framework) are available for the public to read via prominent links from the front page of their website. Anyone can submit comments, including members of the public, other professions and osteopaths from other countries.

The GOsC seems to be interested in listening to the views of anyone who feels they have a stake in this and I would encourage those with strong views to not only participate in the process themselves but also encourage others to do so. The voices of our patients should carry considerable weight in this, if enough of them could be persuaded to get involved, as it is they and not us whose interests the GOsC sees its role as representing."

www.osteopathy.org.uk (http://www.osteopathy.org.uk)

Pebble

26th March 2009, 10:53 PM

Smith

7th April 2009, 06:31 PM

Most current, commonly used medical treatments not supported by good evidence?

http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp (http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp)

How much do we know?

Clinical Evidence aims to help people make informed decisions about which treatments to use. It can also show where more research is needed. For clinicians and patients we wish to highlight treatments that work and for which the benefits outweigh the harms, especially those treatments that may currently be underused. We also wish to highlight treatments that do not work or for which the harms outweigh the benefits. For the research community our intention is to highlight gaps in the evidence, where there are currently no good RCTs or no RCTs that look at groups of people or at important patient outcomes.
So what can Clinical Evidence tell us about the state of our current knowledge? What proportion of commonly used treatments are supported by good evidence, what proportion should not be used or used only with caution, and how big are the gaps in our knowledge? Of around 2500 treatments covered 13% are rated as beneficial, 23% likely to be beneficial, 8% as trade off between benefits and harms, 6% unlikely to be beneficial, 4% likely to be ineffective or harmful, and 46%, the largest proportion, as unknown effectiveness (see figure 1). Dividing treatments into categories is never easy hence our reliance on our large team of experienced information specialists, editors, peer reviewers and expert authors. Categorisation always involves a degree of subjective judgement and is sometimes controversial. We do it because users tell us it is helpful, but judged by its own rules the categorisation is certainly of unknown effectiveness and may well have trade offs between benefits and harms. However, the figures above suggest that the research community has a large task ahead and that most decisions about treatments still rest on the individual judgements of clinicians and patients.

Blue Wode

7th April 2009, 07:29 PM

Smith, you may be interested in this little discussion which is currently taking place in the comments section below a post that Professor Edzard Ernst made to his blog last week...

DrPlato | 05 Apr 09
Prof. Ernst by his own admission is annoyed by what he calls the 'non evidence based fashion' of integrated medicine. Is he aware that the British Journal of Medicine's handbook, Clinical Evidence has a pie chart that shows that only 13%(sic) of conventional commonly used interventions are backed by solid evidence and that another 23% are 'probably of benefit'. (http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp) How in the face of such a statistic, Prof. Ernst can continue using lack of 'evidence' as a club to bash integrated approaches exclusively, only he can explain.

As for the comments by Les Rose, it is clear that he needs to examine the pie chart even more closely than Ernst. If he calls for the GMC and Royal Colleges to 'ensure that doctors practise evidence based medicine' he should ask them to clean up their own house first. Doctors in glass houses certainly shouldn't throw stones. The 64% of 'commonly used' interventions in orthodox medicine that are of doubtful benefit or may even do harm should be the first therapeutic interventions to draw the attention of these regulatory bodies according to people like Rose who insist on evidence based medicine being the only judge of any therapeutic encournter.

Edzard Ernst | 06 Apr 09
The figures on "Clinical Evidence" are an under-estimate; but even if they were correct, they would be about 6 times higher than in alternative medicine. q.e.d.

Brian Kaplan | 07 Apr 09
@Edzard Ernst You say the figures in 'Cinical Evidence' are an underestimate. May I politely ask you for proof of this statement? As a very strong advocate of evidence based medicine, I trust you will soon publish the evidence for calling the BMJ's figures an 'underestimate'.

No evidence for your 'about 6x higher' either. And surely the BMJ's figure of 13% just goes to show that both orthodox and complementary approaches share a 'lack of evidence' for most of their therapeutic interventions - a fact that is conspicuously absent from all your writing. So not QED at all. All you have demonstrated to open-minded physicians is your extreme bias against complementary medicine - the very field in which you are an academic professor.

John Garrow | 07 Apr 09
Dr Plato should not just look at the pie-chart, but also read the text. He thinks the pie chart shows "The 64% of 'commonly used' interventions in orthodox medicine that are of doubtful benefit or may even do harm" but it does not. It is 64% of ALL COMMONLY USED INTERVENTIONS, and most of them are CAM interventions, not orthodox ones. As a cure for wrinkles on the face people wash their face in the dew on the morning of 1st May. That has no evidence of efficacy, but it is not an orthodox therapy!

http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4122268&c=2

(NB. Registration is free)

JJM

7th April 2009, 10:36 PM

{snip} Osteopathy is evolving from a discipline based on anatomical and physiological knowledge, theory and experiential evidence, to a discipline informed by experimental evidence. {snip} It would be unrealistic to expect all this to have happened more rapidly than it has. {snip}I am not very familiar with osteos in the UK; but if, as the name suggests, it is based in Still's 19th century notions then it is based on fanciful ideas of anatomy and physiology. We already know that traditional osteopathy fails.

If you truly want to become competent, there is no need to "evolve." Osteos in the US became competent in medicine decades ago- all you have to do is adopt their model.

I have never understood the notion of "let us practice [our preferred woo] as if the research had been done" till it actually is done.

Pebble

7th April 2009, 10:55 PM

Difficult to know what to make of this site. Their claim is very grandiose, but they have never even heard of pulmonary hypertension despite 15 double blind randomised controlled trials and 7 agents of proven efficacy. Digital ulceration for which there is proven therapy is covered under Raynaud's incorrectly:

The entry reads as follows:

What are the effects of drug treatments for secondary Raynaud's phenomenon?
Beneficial
Prostaglandins (intravenous)
Likely to be beneficial
Bosentan (an endothelin-1 receptor antagonist) (reduced new digital ulcers compared with placebo in people with systemic sclerosis and previous digital ulceration in the last 12 months; however, no evidence in people with secondary Raynaud's without previous digital ulceration)
Calcium channel blockers
Unknown effectiveness
ACE inhibitors
Alpha-blockers
Angiotensin II receptor antagonists
Antithrombotics/inhibitors of platelet aggregation
Glyceryl trinitrate (transdermal)
Inositol nicotinate
Moxisylyte
Naftidrofuryl oxylate
Phosphodiesterase inhibitors
SRIs
Unlikely to be beneficial
Prostaglandins (oral)

Now intriguingly Bosentan has been shown to be ineffective in Raynaud's yet is coded under 'likely to be beneficial' because they are unable to cater for the correct category.

Oral prostaglandins were tested and shown to be ineffective, this therapy therefore was never brought to market. yet here it is being counted as a therapy ostensibly used in practice but likely not to be beneficial.

ACE inhibitors are well proven in renal scleroderma disease (Raynaud's very common in this population), and though not proven for this indication are used because of their known benefits, pending the outcome of trials to determine whether the benefit extends to this subgroup.

The impression is of a group of non experts (except in trial methodology and general specialties) looking at the evidence base, but unaware of the actual practice. I appreciate what they are trying to achieve, might even join them, but even on this mini review their methodology is not robust.

davidrodway

8th April 2009, 12:37 PM

I am not very familiar with osteos in the UK; but if, as the name suggests, it is based in Still's 19th century notions then it is based on fanciful ideas of anatomy and physiology. We already know that traditional osteopathy fails.

If you truly want to become competent, there is no need to "evolve." Osteos in the US became competent in medicine decades ago- all you have to do is adopt their model.

I have never understood the notion of "let us practice [our preferred woo] as if the research had been done" till it actually is done.

Osteopaths in the UK use a range of manual/manipulative techniques , mainly treasting patients with musculo-skeletal complaints. We use clinical diagnostic methods that would be familiar to medics - case history, physical examination etc, including clinical methods. We are vigilant for pathologies that should be referred.

Osteopaths in the States use drugs and sugery, which we are not trained to do. I understand they use little hands-on treatment -possibly leaving the field open to chiropractors, which may be why there are more osteopaths than chiropractors in the UK. Stills ideas are of historical interest only and have little practical application in modern osteopathy in th UK.

Research I have commented on before but will say again that the GOsC and BOA are encouraging research and a research ethos is pushed at the osteopasthic colleges.

JJM

8th April 2009, 06:05 PM

{snip} I have never understood the notion of "let us practice [our preferred woo] as if the research had been done" till it actually is done.

{snip} Research I have commented on before but will say again that the GOsC and BOA are encouraging research and a research ethos is pushed at the osteopasthic colleges.Let me try again, why do you need to provide treatments that have not been researched? Do you think you do something medicine cannot? Since you don't have the data, you don't know.

More than that, we have scientifically based data, lots of it, on musculoskeletal problems and treatments. Proper healthcare providers know those things and furnish the care. As I said, the US model works- simply adopt medicine and become doctors or physiotherapists.

tolman

8th April 2009, 06:25 PM

It's certainly possible that irrespective of original beliefs, osteopaths (and chiropractors) may well either as groups or individuals have developed some techniques which could be usefully incorporated into general physiotherapy.

Has anyone ever attempted to harvest techniques for more widespread use?

If a particular discipline does move towards being more evidence-based ("Doing this manoeuvre can help people with that particular kind of problem"), assuming the surrounding terminology doesn't make such transference hard, is there anything actually stopping one technique after another being picked up by outsiders?

JJM

8th April 2009, 07:14 PM

It's certainly possible that irrespective of original beliefs, osteopaths (and chiropractors) may well either as groups or individuals have developed some techniques which could be usefully incorporated into general physiotherapy.You are assuming it is good to let them flounder-around in ignorance, and treat customers while hoping to stumble onto something. What happens if one goes to an osteo with a real illness? DavidR claims to be trained to diagnose and refer; but chiros here (USA) make the same claim and it is demonstrably delusional.

Look at www.quackwatch.org and www.chirobase.org and read about surveys and undercover visits to chiros. One doctor (Kinsinger) went to eight chiros complaining of symptoms that indicated a medical emergency, none of them referred him to a hospital. How unlucky can a person be to go to the only eight, ignorant chiros in the city; it is more likely that they were representative.

Has anyone ever attempted to harvest techniques for more widespread use? {snip}It is safe to say that osteopathy and chiro have offered nothing of use to medicine here. The only, likely benefit from chiro is for low-back pain of short duration; but it is no better than other treatments (including, simple massage). So, there is nothing to harvest from chiro.

Some chiros, today, claim to have adopted some physiotherapy methods; but they are not trained in that any more than they are trained in medical diagnosis. It simply makes no sense to go to a non-medical person for a medical condition.

tolman

8th April 2009, 07:46 PM

You are assuming it is good to let them flounder-around in ignorance, and treat customers while hoping to stumble onto something.
Thanks so much for telling me what I'm assuming.
Whether or not I think it is good doesn't have any bearing on what's actually going to happen.
No-one official seems likely to jump in and tell people to stop doing anything until they've demonstrated that each and every intervention actually works, at least not unless there are a string of well-publicised deaths and/or court cases.

Some chiros, today, claim to have adopted some physiotherapy methods; but they are not trained in that any more than they are trained in medical diagnosis. It simply makes no sense to go to a non-medical person for a medical condition.
But if some people *are* going to go to them for things other than back pain, it does seem to make sense for them to have some skills that might result in people being referred back to regular doctors.

If a particular group does claim to be able to diagnose, doesn't that put them on a rather dodgier legal footing if they fail to do it properly and someone suffers as a result?

JJM

8th April 2009, 08:29 PM

Thanks so much for telling me what I'm assuming.No charge for that, mate.

{snip} No-one official seems likelyThanks for telling me what officials are likely to do.

But if some people *are* going to go to them for things other than back pain, it does seem to make sense for them to have some skills that might result in people being referred back to regular doctors.Some skills are not enough. In fact, they have a limited set; but they are deluded into thinking it is complete- hence, if Kinsinger were really a sick person as he claimed, he could have been seriously injured. We have a saying that people know just-enough to be dangerous.

If a particular group does claim to be able to diagnose, doesn't that put them on a rather dodgier legal footing if they fail to do it properly and someone suffers as a result?That is a good question. Remember- the law is a ass. Once one is licensed, one is subject to the "standard of care" decided by other chiros. If the chiro board asserts that a certain missed diagnosis is within the standard of care, there may be no criminal prosecution. However, anyone can be sued for anything in civil court and be made to make restitution. There was a recent case (not a diagnosis problem) that illustrates the "standard of treatment" problem. A chiro was fondling women's breasts, I think he lost and had to pay; but he had chiro "expert witnesses" who testified that what he did fell within standard practice.

tolman

8th April 2009, 08:56 PM

Thanks for telling me what officials are likely to do.
I'm making an assessment of what seems likely, based on a long and consistent history of relative inaction, since I can't actually go and ask all the relevant people directly.
That's rather different than leaping to unfounded conclusions about what someone else thinks when you could just as easily ask them.

Some skills are not enough. In fact, they have a limited set; but they are deluded into thinking it is complete- hence, if Kinsinger were really a sick person as he claimed, he could have been seriously injured. We have a saying that people know just-enough to be dangerous.
The point is that if you can't actually stop people going to see them, some skills are better than nothing, unless it's possible to get them to make a disclaimer that they don't have the skills.
If people actually are deluded into thinking they have skills, unless you can undelude them or stop them working, the next best thing seems to be for them to acquire abilities that more closely match their claims.

That is a good question. Remember- the law is a ass. Once one is licensed, one is subject to the "standard of care" decided by other chiros. If the chiro board asserts that a certain missed diagnosis is within the standard of care, there may be no criminal prosecution. However, anyone can be sued for anything in civil court and be made to make restitution.
Surely, irrespective of any internal standards of care, the more noise a professional body makes about their diagnostic skills, the more expectations are reasonably raised amongst the general public that those claimed skills exist among the members.

JJM

8th April 2009, 10:39 PM

{snip} The point is ... some skills are better than nothing, {snip}No. We have another saying "A little knowledge is a dangerous thing." Do you see that point? Consider the guy, several years ago, who knew that it was fun to jump off a promontory attached to a bungee cord to arrest his plunge. So, he jumped headlong off the 30-foot height ... attached to a 40 foot cord. Do you get it now?

Let's try another. I was working in a building that was maintained at 60 degrees F over the summer (outside temps ranging into the 90s); at the same time they were taking out 25% of the light bulbs in order to conserve electricity. The reduction in lighting annoyed me and I remarked that they could obviously save a lot more electricity by only cooling the place to 70. However, the way the power plant was built, the air was chilled to 60 (to dry it) and then re-heated to 70 to be comfortable. So, keeping the air at 60F saved electricity.

Do you understand that one can know little-enough to be "dangerous" (in a given context).

JJM

8th April 2009, 11:13 PM

{snip} If people actually are deluded into thinking they have skills {snip}Try this- a stopped-clock is right twice a day. Would you consult such a clock for the time? Would you consult a health-care provider who is similarly inaccurate?

tolman

8th April 2009, 11:37 PM

No. We have another saying "A little knowledge is a dangerous thing." Do you see that point? Consider the guy, several years ago, who knew that it was fun to jump off a promontory attached to a bungee cord to arrest his plunge. So, he jumped headlong off the 30-foot height ... attached to a 40 foot cord. Do you get it now?

Let's try another. I was working in a building that was maintained at 60 degrees F over the summer (outside temps ranging into the 90s); at the same time they were taking out 25% of the light bulbs in order to conserve electricity. The reduction in lighting annoyed me and I remarked that they could obviously save a lot more electricity by only cooling the place to 70. However, the way the power plant was built, the air was chilled to 60 (to dry it) and then re-heated to 70 to be comfortable. So, keeping the air at 60F saved electricity.

Do you understand that one can know little-enough to be "dangerous" (in a given context).
If you wish to [attempt to] patronise me, you could at least try and read what I wrote first, rather than wasting your time with examples of no relevance.

If there are people with few or no diagnostic skills who claim to have them (or at least believe they have them), then ideally, someone would stop them thinking that way, or stop them coming in contact with people they could potentially harm.

However, if those people have evidently been in business for generations without causing sufficient publicised harm to cause them to be stopped, then unless something significant has changed recently or changes in future, it seems likely that they will remain in business in at least the medium term, whatever my (or your) opinion of them may be.

In that case, it doesn't seem a bad thing if their skills improve such that the gap between their abilities and their beliefs (or their clients' beliefs) about their abilities becomes smaller.

The point about something being better than nothing is that if 'nothing' appears to be the only likely other option, 'something' may still be better even if it's clear that it isn't what some would consider as ideal.

Pebble

8th April 2009, 11:43 PM

It's certainly possible that irrespective of original beliefs, osteopaths (and chiropractors) may well either as groups or individuals have developed some techniques which could be usefully incorporated into general physiotherapy.

Has anyone ever attempted to harvest techniques for more widespread use?

If a particular discipline does move towards being more evidence-based ("Doing this manoeuvre can help people with that particular kind of problem"), assuming the surrounding terminology doesn't make such transference hard, is there anything actually stopping one technique after another being picked up by outsiders?

Physiotherapy has been around for around 100 years now and is considerably more evidence based than osteopathy - at present. Whether concepts from osteopathy have influenced physiotherapy is unclear, but the fact that the newer specialty has embraced an evidence based approach but not the supposed precursor suggests that under the rules of evolution the predecessor should become extinct.

tolman

8th April 2009, 11:50 PM

If people actually are deluded into thinking they have skills,Try this- a stopped-clock is right twice a day. Would you consult such a clock for the time? Would you consult a health-care provider who is similarly inaccurate?
I'm trying to see some kind of logical connection between what I wrote, the brief snippet you quoted, and your response, but it's really not clear what you think the connection is.

tolman

9th April 2009, 12:21 AM

Whether concepts from osteopathy have influenced physiotherapy is unclear, but the fact that the newer specialty has embraced an evidence based approach but not the supposed precursor suggests that under the rules of evolution the predecessor should become extinct.
Surely, evolution would suggest that species tend to hang on until they're outcompeted in their particular niche.
If the customers aren't hugely bothered whether something is (or claims to be) evidence-based, then that factor won't weigh much into their choices.

The couple of people I know who've used chiropractors seem to have done so not because they had any particular belief, but because the [general] physiotherapists they could get free access to weren't actually any good for them - their skills seemed more directed to treating elderly people rather than younger people with different kinds of problems. Similarly, other people I know have ended up happily paying for private physios after having basically the same poor experience.

It wasn't a case of a direct comparison between specialties as a whole - the chiropractor only had to be better than a physio who either wasn't particularly good, or whose particular skills and experience weren't relevant to the condition in question.

It may well be that a good physio would have solved the problems that ended up being taken elsewhere, but often the course followed is to try the regular phsyio, and if that doesn't work, ask around for alternatives.
As long as other specialities seem to produce satisfied customers, especially for the kinds of things that even non-believers might still think they *could* be good at, they're likely to get business from recommendation in the same way that a good private sports physio is.

Smith

9th April 2009, 07:10 AM

http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4122268&c=2

John Garrow | 07 Apr 09
Dr Plato should not just look at the pie-chart, but also read the text. He thinks the pie chart shows "The 64% of 'commonly used' interventions in orthodox medicine that are of doubtful benefit or may even do harm" but it does not. It is 64% of ALL COMMONLY USED INTERVENTIONS, and most of them are CAM interventions, not orthodox ones. As a cure for wrinkles on the face people wash their face in the dew on the morning of 1st May. That has no evidence of efficacy, but it is not an orthodox therapy!

I have not checked John Garrow's assertion as full access to clinicalevidence.bmj.com is restricted to paid subscribers. But let's follow the Pulse thread further...

DrPlato | 07 Apr 09
@ John Garrow You say in reference to the pie chart: 'and most of them are CAM interventions, not orthodox ones' Where is your evidence for this statement? Where exactly in the text (that you claim I haven't read) does it say that 'most of them are CAM'? Even Prof. Ernst (in his comments here) implicitly accepts the figures but (without evidence) - says they are an 'underestimate' Please accept my apologies for any embarrassment caused by my repeated calls for evidence to justify medical statements of any kind. Apparently we live in an 'evidence based society' these days so I've learned to do as the Romans do...

DrPlato | 07 Apr 09 @ John Garrow Your illustration is very 'interesting'. It impiies that every crackpot 'cure' for anything including witchcraft and things similar to the ridiculous example you give, was included in the pie chart - which is therefore of no value to anyone. I think you should write to the BMJ and tell them to stop publishing misleading pie charts about the efficacy of therapeutic interventions - especially those that are insulting to experts who use 'lack of evidence' as a reason to rubbish complementary and alternative approaches - leaving the impression that most of orthodox interventions and the 'conventional' stuff for sale in chemists is actually based on evidence.

Smith

9th April 2009, 07:15 AM

but the fact that the newer specialty has embraced an evidence based approach but not the supposed precursor suggests that under the rules of evolution the predecessor should become extinct.

Assuming some sort of selective advantage to EBM.

Well, in the UK at least, it clearly isn't working that way right now, as osteopathy becomes ever more popular!

Pebble

9th April 2009, 07:37 AM

Here you go Smith:

Looking down this list it is quite evidence that the majority of these have no place in conventional medicine. Indeed if you go to your GP and ask for treatment for wrinkles, be sure to stand close to the door.

Presumably occasional Harley Street Dermatologists are practicing CAM despite having a medical degree and this is the justification for their inclusion.
What are the effects of treatments for skin wrinkles?

Trade off between benefits and harmshttp://clinicalevidence.bmj.com/images/icon-tradeoff.gif (http://clinicalevidence.bmj.com/ceweb/about/guide.jsp#icons)

Isotretinoin (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I6.jsp)
Tazarotene (improved fine wrinkles) (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I12.jsp)
Tretinoin (improved fine wrinkles) (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I4.jsp)
Unknown effectivenesshttp://clinicalevidence.bmj.com/images/icon-unknowneffectiveness.gif (http://clinicalevidence.bmj.com/ceweb/about/guide.jsp#icons)

Carbon dioxide laser (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I10.jsp)
Chemical peel (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I11.jsp)
Dermabrasion (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I9.jsp)
Facelift (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I14.jsp)
Glycolic acid or lactic acid (topical) (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I15.jsp)
Oral natural cartilage polysaccharides (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I8.jsp)
Retinyl esters (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I5.jsp)
Topical natural cartilage polysaccharides (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I7.jsp)
Variable pulse erbium:YAG laser (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I13.jsp)
Vitamin C or E (topical) (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I3.jsp)

Smith

9th April 2009, 07:43 AM

I am not very familiar with osteos in the UK; but if, as the name suggests, it is based in Still's 19th century notions then it is based on fanciful ideas of anatomy and physiology.

Clearly you are not. To be inspired as a group by certain principle ideas is one thing. But osteopaths in general do not work with a 19th century mindset or knowledge base. That is a fanciful notion.

We already know that traditional osteopathy fails.

Do we? Isn't that too much of a blanket statement? Where and to what extent does it fail, and how do "we" know? Where and to what extent does it succeed?

If you truly want to become competent, there is no need to "evolve." Osteos in the US became competent in medicine decades ago- all you have to do is adopt their model.

UK osteopaths are highly trained and in general, I believe, competent. Perhaps you could spell out for me the advantages of the US model osteopathic physician?

I have never understood the notion of "let us practice [our preferred woo] as if the research had been done" till it actually is done.

I think the overarching principle should be the overall good for society; of, on the one hand, limiting people's choice to a model espoused by a vocal minority (only scientifically proven treatments allowed), or allowing people the freedom to decide how they will manage their own health. My preference is for the latter. I base this on my assumption (yes) that many people want alternatives to drug medicine, and want to be in charge of their own health decisions.

I think we agree on the need for excellence in training. I think we agree too that any information given about the applications of treatment methods should be backed by an explanation of their basis (scientific research, collective experience, personal experience, or simply opinion).

Pebble

9th April 2009, 07:51 AM

Another interesting snippet: The notion that face lifts require RCTs to demonstrate the ability of this procedure to reduce wrinkles is extraordinary. Given an effectiveness of 100% in this respect, no trial is necessary. If the question was phrased in respect of wrinkle freedom/reduction at 5 years then there would be some merit. This is therefore an inappropriate use of the methodology.

Facelift

In this section:

Summary (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I14.jsp#summary) | Benefits (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I14.jsp#benefits) | Harms (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I14.jsp#harms) | Comment (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_I14.jsp#comment)
Top (javascript:scrollTo(0,0);)
Summary

We found no direct information about the effects of facelifts in people with wrinkles.
For GRADE evaluation of interventions for wrinkles, see table (http://clinicalevidence.bmj.com/ceweb/conditions/skd/1711/1711_T3.jsp).

Top (javascript:scrollTo(0,0);)
Benefits

We found no systematic review and no RCTs.
Top (javascript:scrollTo(0,0);)
Harms

We found no RCTs.
Top (javascript:scrollTo(0,0);)
Comment

Clinical guide:

The effectiveness and safety of facelift surgery is likely to depend on the technique of the surgeon.
http://clinicalevidence.bmj.com/images/button-close.gif (javascript:hide();)
Loading...

Smith

9th April 2009, 07:59 AM

Pebble, thanks for that, but I can't really comment on these treatments - not my field.

But you say: "Presumably occasional Harley Street Dermatologists are practicing CAM despite having a medical degree and this is the justification for their inclusion."

Clinicalevidence.bmj.com on the other hand apparently believe these are "commonly used treatments" (not "occasionally used treatments").

How many of these treatments would be used by non-medic CAM practitioners? The vitamins and the natural cartilage polysaccharides only I should imagine. But the point is many are claimed to be "commonly" used by doctors. So is medicine riddled with... erm (cringe).."woo", too?

Blue Wode

9th April 2009, 08:07 AM

I have not checked John Garrow's assertion as full access to clinicalevidence.bmj.com is restricted to paid subscribers. But let's follow the Pulse thread further...
I think it would be best to wait for John Garrow's response. In the meantime, here's a scientific source which suggests that around 78% of medical practices are based on reasonable scientific evidence:
http://www.theness.com/neurologicablog/?p=51 (http://www.theness.com/neurologicablog/?p=51)

Blue Wode

9th April 2009, 08:17 AM

Surely, evolution would suggest that species tend to hang on until they're outcompeted in their particular niche.
In which case, evolution could be seeing chiropractors - who share many similarities with UK osteopaths - on the road to a gradual demise in the US.

Dwindling market share…

The profession still finds itself in a situation in which it is rated dead last amongst healthcare professions with regard to ethics and honesty [2], and in which only 7.5% of the population utilizes its services [3], this percentage having dwindled from 10% only a short time ago [3,4]
http://www.chirobase.org/01General/respect.html (http://www.chirobase.org/01General/respect.html)

Competition from physios…

As I warned in Bonesetting, Chiropractic and Cultism, if chiropractic fails to specialize in an appropriate manner, there may be no justification for the existence of chiropractic when there are an adequate number of physical therapists providing manipulative therapy.

Many physical therapists are now using manipulation/mobilization techniques. Of the 209 physical therapy programs in the US, 111 now offer Doctor of Physical Therapy (DPT) degrees. Some of these programs have been opened to qualified chiropractors. According to the American Physical Therapy Association, “…Physical therapy, by 2020, will be provided by physical therapists who are doctors of physical therapy and who may be board-certified specialists.

Consumers will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services. Physical therapists will be practitioners of choice in patients’/clients’ health networks and will hold all privileges of autonomous practice…”

It matters little who does spinal manipulative therapy as long as it is appropriate and evidence-based.

More…
Can Chiropractors and Evidence-Based Manual Therapists Work Together? An Opinion From a Veteran Chiropractor, Journal of Manual & Manipulative Therapy, Vol.14 No.2 (2006) E14-E18
http://jmmtonline.com/documents/HomolaV14N2E.pdf (http://jmmtonline.com/documents/HomolaV14N2E.pdf)

The Hard Times scenario…

Big Lou Sportelli, former ACA and WFC notable and now chairman of NCMIC, boldly asked in the opening plenary session, no doubt shocking the audience, “Where the hell are we going?” before he introduced Dr. Clem Bezold from the Institute of Alternative Futures, who answered that question when he gave a glimpse of our future possibilities, The Future of Chiropractic Revisited—2005-2015. [http://www.altfutures.com] (http://www.altfutures.com%5d/)

Although four possible scenarios were given by Dr. Bezold, it’s clear the worst case scenario, Scenario #2: Downward Spiral, is the most accurate now inasmuch he said 15% of DCs have quit the profession. Meanwhile, there has been a 39% drop in chiro education student enrollment from 1969-2002 and, while the use of CAM in general has increased, the largest decrease occurred for chiropractic (9.9% to 7.4%) according to the recent Eisenberg study. Indeed, there’s little to cheer about when faced with the hard facts about this profession.

If these stats don’t cause anxiety for you, perhaps Dr. Bezold’s Hard Times Scenario will. While some may argue more optimistically about the current status/future of this profession, Dr. Bezold’s characterizations certainly didn’t seem as hopeful.

He characterized this scenario as the Hard Times Scenario:

* External trends go against chiropractic; chiropractic misses many of the opportunities presented. [FSU; Trigon, HHS lawsuits]

* Cost Squeeze in healthcare: economic downturn; pressure to reduce costs [ASHN]; chiropractic looses coverage mandates. [Ontario]

* Public Relation disasters: no public outreach campaign, disunity in the profession, highly visible malpractice cases grad media attention [Markson lawsuit, Life debacle, Gallagher conviction, to name but a few]

* Little Evidence of improved efficacy: SMT is not proven better than mobilization, massage, or self care; outcomes are not monitored. [Where’s our research?]

Dr. Bezold also mentioned the challenges we face on the demand side of medical economics:

1. Cost squeeze in healthcare: all payors will look to costs and restrict benefits.

2. Cultural Legitimacy: chiropractic will have to ‘play in the system’ to increase its share of the healthcare pie.

3. Evidence/Outcomes Based Medicine (EBM): will be a deciding factor on who wins and loses in the healthcare market.

He also mentioned our competition is also encroaching more than ever before: by 2012 we will be greatly outnumbered by those within the mainstream treating similar cases:

1. 70,000 DCs
2. 185,000 PTs
3. 117,000 MTs
4. 27,000 Acupuncturists

http://chirotalk.proboards.com/index.cgi?action=display&board=outlook&thread=804&page=1 (http://chirotalk.proboards.com/index.cgi?action=display&board=outlook&thread=804&page=1)

With regard to the future of osteopathy and chiropractic in the UK, once again it’s worth bearing this in mind:

“Prospective, controlled, cost-effectiveness studies of complementary therapies have been carried out in the UK only for spinal manipulation (four studies) and acupuncture (two studies). The limited data available indicate that the use of these therapies usually represents an additional cost to conventional treatment.”

Cost-Effectiveness of Complementary Therapies in the United Kingdom—A Systematic Review (2006)
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17173105 (http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17173105)

“One controlled study of a medical osteopathy service found that service users did not decrease their use of NHS resources.”

The impact of NHS based complementary therapy services on health outcomes and NHS costs: A review of service audits and evaluations (2009)
http://7thspace.com/headlines/304871/the_impact_of_nhs_based_complementary_therapy_serv ices_on_health_outcomes_and_nhs_costs_a_review_of_ service_audits_and_evaluations.html (http://7thspace.com/headlines/304871/the_impact_of_nhs_based_complementary_therapy_serv ices_on_health_outcomes_and_nhs_costs_a_review_of_ service_audits_and_evaluations.html)

“There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.”

http://www.cochrane.org/reviews/en/ab000447.html

However, I suspect that the new NICE guidelines on low back pain - which are due to be published next month – will keep UK osteopaths and chiropractors in undeserved business for many years to come.